Barbara Patterson

From the Lord Prior of Brampton Parliamentary Under Secretary of State for NHS Productivity (Lords) Department Kx of Health Richmond House RECEIVED 79 Whitehall Ms C. Henley London Assistant Coroner 2 1 JUL 2015 SWIA ZNS 17 Church Street Tel: Berwick-upon-Tweed TDI5 IEE 2 0 JUL 2015 hu 0S, Thank you for your letter 0f 21 2015 following the inquest into the death of Barbara Patterson. Iwas very sorry to hear of Mrs Patterson' $ death and wish to extend my sincere condolences to her family. You raise several concerns which relate to the level of ambulance service which was provided to Mrs Patterson: Failure by call handler to give timely advice in respect of CPR. The Pathways system piloted in the North East has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing: Although this fault was pointed out to Pathways by NEAS NHS Trust manager before the latest update of the system (early 2014), Pathways refused to amend the system. The fault remains in place. Failure by ambulance dispatcher to dispatch ambulance closer to deceased 's location. Target time for arrival was 8 minutes but the ambulance took 15 minutes t0 arrive. National shortage of paramedics particularly in the North East Ambulance availability is jeopardised by crews being delayed at hospital when handing patients over to A&E staff: The most immediate concern is about the lack of timely advice provided to Mrs Patterson's family by the ambulance call handler: [ understand you have been told the handler was following the protocol and procedures from the NHS pathways call handler system (Clinical Decision Support System (CDSS) Although Mrs Patterson would not have survived the stroke, YOu were told the system did not advise that CPR should be on this occasion, because the patient had not stopped breathing: You consider this is a fault in the that needs to be remedied. May applied system

NHS Pathways has provided a response to your concerns (attached) which includes an overview of the CDSS system, how it is implemented, reviewed and updated and the amendments that are made to supporting information on breathing assessment breathing is already identified as a major airway compromise that requires an emergency response and appropriate CPR advice. NHS Pathways believes the call-handler might have failed to pick up the cues which should have led to this advice given. The target for an emergency ambulance response is that 75% of all Red 1 calls the most serious, life-threatening category - receive a response within eight minutes. While ambulance services will always attempt to provide a response aS soon as possible in life-threatening situations, the target recognises that it is unfortunately not always physically possible for ambulance services to respond to all Red 1 calls within eight minutes. The North East Ambulance Service (NEAS) is currently unprecedented demand. NEAS has made progress in recruiting to vacancies, reducing its paramedic shortfall to 21% at the end of April 2015,and will continue to recruit more paramedics I understand that NEAS has separately provided you with its response to the issues you raised. To improve services nationally, NHS England's National Medical Director, Professor Sir Bruce Keogh; undertook a review of urgent and emergency care in 2013. This aims to change the way services are provided, including shifting care outside of the hospital setting where clinically appropriate, thereby avoiding unnecessary journeys and admissions to hospital. The review proposes transforming the urgent and emergency care system by: providing better support for people to self-care; helping people with urgent care needs to get the right advice in the right place, first time; providing highly responsive urgent care services outside of hospital SO people no longer choose to queue in A&E; ensuring that those people with more serious or life threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and recovery; and connecting all urgent and emergency care services together s0 the overall system becomes more than just the sum of its parts. Noisy being facing good

Department of Health Some of the proposed changes are already underway, affecting NHS 111, community pharmacy and developing the ambulance service as a mobile treatment service rather than solely a transportation service. Hospital handovers, the process whereby the hospital takes over responsibility for the patient from the ambulance service, should occur within 15 minutes of the ambulance'$ arrival at the A&E department: The ambulance crew cannot leave the patient to attend further calls until the hospital has formally assumed responsibility. There is no single cause for handover delays and local factors often contribute. Patient handover therefore needs to be as efficient as possible both to achieve the best possible outcome for the patient and to free ambulance resource. Some ambulance services and A&E departments have introduced Hospital Liaison Officers to act as a single of contact between services. Other work aims to improve the discharge process and patient This includes reducing delays for patients moving between NHS and social care organisations so more beds become free. NHS England is preparing guidance for Urgent and Emergency Care Networks designed to improve patient flow within the urgent and emergency care Work will continue to increase the number of Physician Associate training programmes across England in order to meet the workforce needs of acute, community and primary care providers. HEE will also ensure that paramedic training provides an additional 16% growth 1,900 additional paramedics in the current workforce over the next five The skills and abilities of paramedics and the wider workforce also need to be utilised more fully. This will help ambulances to become mobile treatment services, rather than transport services, so that more patients can be treated at scene, where clinically appropriate. We are extending paramedic training to enable them to better assess, prescribe for and manage patients with chronic illnesses. They need to work more closely with GPs and community teams_ In support of this, NHS England plans to publish guidance to help ambulance services develop these new ways of working: point flow. system years.

I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Mrs Patterson's death to my attention DAVID PRIOR

Dear Mr Brown Re: Inquest into the death of Barbara Patterson. We were sorry t0 read about the death of Ms Patterson and the circumstances in which she died: Thank you for your report and the requirement for uS to review what actions should be taken; Please treat this letter as the formal response of the Care Quality Commission (CQC) to your report dated 21
2015. In your report and pursuant to the requirements under paragraph 7 , schedule 5 of Coroners Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013,you require the CQC to provide details of any action that has been taken or which is proposed to be taken in response to the concerns highlighted in your report; or an explanation as to why no action is proposed if appropriate. Background Before the death of Barbara Patterson we carried out unannounced visits to North East Ambulance Service NHS Foundation Trust (NEAS) which involved visits to four ambulance stations and the emergency control centre on 4, 5,6, 7 and 13 February 2014, Following that inspection we identified areas of non compliance against the following regulations detailed in the Health and Social Care Act (2008): Regulation 10 (1)(b)(2)(b)i) Assessing and monitoring the quality of service provision; May the

Regulation 13 Management of Medicines; Regulation 23(1)a) Supporting Workers; Regulation 21(a)(i) Requirements relating to workers; Following submission of the final report we instructed NEAS to submit an action plan_ The Action Plan was presented to CQC by NEAS within the required timescale and, recognising that the Service required a reasonable period of time to implement the proposed measures, regular meetings were scheduled and conducted between CQC and NEAS, to monitor the progress of their implementation. This process was undergoing at the time of Mrs Patterson's death. Matters_ot Concern
1. The failure of the call handler to give out timely advice in respect of CPR; The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence t0 demonstrate that understand their role and responsibilities in relation to call handlers and that provide regular monitoring to ensure that the system is functioning at an appropriate ievel.
2. Deficiencies in Pathways System As recognised in your report; the Pathways system is a National Programme, piloted in the North East; which has been introduced in other areas of the country: We have written to NEAS to instruct them to submit evidence of how are mitigating the risk within the Pathways system and also how they are working with Pathways to improve the system: 3 Failure of ambulance dispatcher to dispatch an ambulance closer to the deceased's location This issue will be included as part of our planned comprehensive inspection and investigated to ascertain whether procedures presently in place by NEAS relating to the dispatch of ambulances is appropriate and what;, if any; improvements can be made to the current system. Additionally, we will be meeting with NEAS in September 2015 to discuss how they are managing the process of dispatching ambulances 4 Target time for arrival of ambulance in 8 minutes was breached: This issue will be included as part of our planned comprehensive inspection and investigated to ascertain whether procedures presently in place relating to dispatch duly they they they-

of ambulances is appropriate and what; if any, improvements can be made to the current system: We have written to NEAS to instruct them to submit evidence of their current position around breaches of arrival times of their ambulances together with providing evidence of how are mitigating the risk for of reducing the missed target times of ambulance arrivals.
5. National shortage of paramedics, which is particularly acute in the North East We will be meeting with NEAS in September 2015 to discuss and monitor how are managing their delivery of the service; what is their current position of staffing levels and identified vacant posts and their current recruitment position 6 Delay at handover of patients to A & E staff which jeopardises availability of ambulance staff We will be meeting with NEAS in September 2015 to discuss how are managing the handover process to A & E services and hOw are working collaboratively with all providers and stakeholders to ensure a smooth and timely handover process. In addition, this issue will be reviewed as part of our planned full comprehensive inspection of North East Ambulance Service (NEAS): We greatly appreciate the information you have provided us in your report and please do not hesitate to contact me with any further questions you may have. With best wishes_