Oliver Hall

Dear Mr Parsley,

I write in reply to the concerns you raised with me on 17 June 2019 as Chair of the Association of Ambulance Chief Executives (AACE) through a Regulation 28 PFD report following the inquest of Master Oliver Hall.

Firstly, we would like to offer our condolences to the family and those affected by this tragic passing.

To clarify, AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance services however we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.

I will address your three key concerns in the order given:

1) It is apparent that there is a failure in the process of the transfer information regarding a patient’s original disposition by the NHS 111 Service to the ambulance service and treating clinicians on the ground....It was then identified that the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with relevant information.

The failure to transfer the most relevant information in this instance is very regrettable. English ambulance services use a number of different Computer Aided Dispatch (CAD) systems and one of two authorised triage platforms to assist them in handling emergency calls effectively. From the narrative report of the inquest, it is clear that information was originally given to the ambulance control room by the NHS 111 service that was not then fully shared with the ambulance resource deployed.

Our Ref: ACM/MF/KAF

Date: 11 August 2019

Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI

Having consulted with our National Heads of Control Services Group, it is apparent that the process of sharing this information is necessarily selective. This is partly to avoid overburdening clinicians/responders with excessive or non-relevant information and partly because the mobile data terminals in responding resources (ambulances or cars) have limits on what can be displayed. The systems used vary across the country and the exact nature of what is displayed in the vehicle is determined by the individual ambulance service within the limits of the technology it utilises. We understand that East of England Ambulance Service has reviewed their local processes to take on board your concerns.

Although the process and systems are well established, improvements can always be made. I am pleased to inform you that during 2020/21 elements of the new National Emergency Services Mobile Communication Programme will be implemented across all ambulance services and this will include a greater ability to manage information through the new National Mobilisation Platform. This may in turn allow us to further standardise the types of information displayed on the mobile data terminals in ambulance vehicles.

2) Your concern regarding medical professionals being able to make an informed decision with regard to possible delays in ambulance attendance and that under the current system (highlighted in this case) a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less

Work has been ongoing over the last two years to improve the handling of emergency calls received from Health Care Professionals (HCP). NHS England have now published the National Framework for Healthcare Professional Ambulance Responses which clarifies the new roles and processes. The section reprinted below is pertinent in this instance

HCP Level 2 (HCP 2) Category 2 (18 Minute mean response time)

This level of response is based on the clinical condition of the patient and their need for immediate additional clinical care in hospital in an emergency department or acute receiving unit (i.e. medical or surgical assessment unit, delivery suite).

Patients with a National Early Warning Score (NEWS2) of 7 or greater may trigger a request for this level of response, as may the opinion of a HCP who has assessed the patient.

Patients with a NEWS2 of 6 or less may be suitable for an HCP Level 2 response by exception only and HCPs, where possible, should detail the clinical reason. Examples in this category may be patients with sepsis, myocardial infarction, CVA, acute abdomen, acute ischaemic limb, acute pancreatitis, major gastrointestinal haemorrhage and overdose requiring immediate treatment.

Whilst these calls may be flagged within the Trust CAD system as being from a HCP (for AQI reporting purposes), they must be presented and displayed in the Trust CAD system in the same way as Category 2 calls from the public and responded to accordingly.

In essence, it is the patient’s condition that determines the prioritisation of response so that a call from an HCP will receive the same level of response as that of a public 999 call – driven by the clinical condition of the patient.

Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI

Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call taker to give accurate information regarding the expected time of arrival of a response. This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for a responding ambulance to be diverted from one emergency to another that has been assessed as more urgent or indeed for a responding ambulance to be flagged down at another incident they may be passing. For these reasons, call takers do not commit to an estimated time of arrival, rather they are asked to say ‘help is on its way and please ring back if the patient’s condition changes’.

3) A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year.

Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be influential on its own. The attending ambulance staff have been taught that the assessment of the child with regard to severity of illness and possible causes would be influenced by a range of observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only by doing this that information received can be verified and form part of subsequent decision making.

Ambulance services are all supportive of the clinical guidelines used across the UK and developed by JRCALC but are fully cognisant that these are guidelines for interpretation as are those published by other organisations.

Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff.

I trust you feel that I have answered your concerns fully and thank you for bringing them to my attention.

Dear Mr Parsley, Re: Regulation 28 Oliver Hall (17th June 2019) am writing to you following the inquest of Mr Oliver Hall and the Trusts receipt of a Regulation 28. In order to address your concerns, as outlined in Section 5, will outline the Trusts current position and areas which are being considered for changelbeing changed. Process of the transfer of information regarding patient's original disposition by the NHS 111 service to the Ambulance service and the treating clinicians; the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP's) with relevant information: The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system , some of which also use the same triage system (Pathways) as UK 111 providers The initial stage of this consultation is to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources using existing technology: Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff;, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways. The current system will not identify to medical professional delay which is outside (just under) the category for that call, for example a call is made by a medical professional requesting an ambulance and one is not immediately available will be informed of an anticipated response time outside of the performance times for that category of call; For C2 the medical professional will only be told if the anticipated delay will be 40 minutes or longer: As heard in evidence at the inquest communication had been sent to stakeholders, including lhe cinical Commissioning Groups, regarding the Ambulance Response Program (ARP) call categories in September 2018_ However, he was unable to find evidence that GP's in the region had received further communication regarding how these new categories related to 999 calls made by Health Care professionals_ Interim Chief Executive; Dorothy Hosein Chair: Nigel Beverly WWWeastamb nhs_uk the they key key

The Trust; along with all UK Ambulance Trusts, will shortly be implementing the National Framework for Healthcare Professional Ambulance Responses. The aim of this framework is to standardise nationally how calls from HCPs are {riaged and responded to in line with the ARP call categories and to identify those palients who require immediate clinical intervention as well as transportation. Further information can be found at: https ILwwwengland nhs uklpublication/healthcare-professional-ambulance-responses-frameworkl The Trust currently is aiming to implement this framework on 24"h September 2019 and as part of this implementation stakeholders , such as Clinical Commissioning Groups and Health Care Professionals (HCP) across the region, will receive updated and comprehensive guidance including the call categories associated with HCP calls A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college's ambulance Iiaison committee , specifically in matters of the pulse rate of 120 in a six year_ The National Institute for Health and Care Excellence (NICE) has guideline NG51 ~'Sepsis: recognition, diagnosis and early management' This guidance was published in July 2016 and updated September
2017. NICE formally recognise and endorse the work and decision support tools of the UK Sepsis Trust When reviewing the UK Sepsis Trust 'Sepsis screening tool prehospital (age 5-11)', red flag sepsis is considered if there is a severe tachycardia_ The screening tool goes onto define a severe tachycardia as a heart rate greater than or equal to 120 beats per minute for children aged six to seven years of age: This is further reinforced on the NICE 'Sepsis risk stratification tool: children aged 5-11 years out of hospital'_ Guidance issued by NICE provides clarity surrounding the recognition and identification of high risk criteria in Sepsis_ For any patient presenting with high risk sepsis the patient should be urgently seen in an emergency care setting with resuscitation facilities_ NICE states that for children aged 5-11 years, low and moderate to high risk criteria could be treated in an of hospital setting if the condition can be definitively diagnosed and treated. The UK Ambulance Services Clinical Practice Guidelines 2016 (JRCALC) identify that six-year-old child would be expected to have a heart rate of 80-120 beats per minute. In the 2016 guidelines, sepsis in children is covered in a section pertaining to febrile illness in children and the guidance not greatly developed_ A new 2018 update has just been launched, within this is update there is greater depth of information that; whilst formatted in a different way does broadly align to NICE guidance. EEAST has, for a number of years followed and endorsed the work of UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our 'Clinical Manual' an electronic resource available to staff that is designed to augmenf the guidance offered by JRCALC Kind regards, Dorothy Hosein Interim Chief Executive Interim Chief Executive; Dorothy Hosein Chair: Nigel Beverly WWW eastambnhs uk the key out the