Sabrina Stevenson

Dear Dr Brittain Thank you for your Regulation 28 Report to prevent future deaths, dated 30 March 2015, bringing to my attention the Coroner’s concerns arising from the inquest into the death of Sabrina Stevenson. We have given careful consideration to each concern and consulted with the National Ambulance Service Medical Directors’ Group, our Consultant Midwife, and other senior clinicians within the London Ambulance Service NHS Trust to reply. Taking the concerns in turn I set out the actions we have taken and response:
1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.

On 23 April 2015 I wrote to all LAS staff to inform them of the additional investment the LAS had secured. “I wanted to share the news that we are in final negotiations with our GP commissioners about investing around an additional £27.2m for 15\16, including funding for increased activity. A further £5m will be funded from within the Service. This funding from GP clinical commissioning groups will be released over the year as we achieve milestones around performance, recruitment and productivity.

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The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff rest-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals. To help manage the increased demand we are growing the workforce, responding to patients in new ways and improving the way we work. A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital. We hope to finalise the contract in the next few days, but I wanted to keep you informed of progress.” On 14 May 2015 the LAS Operating Plan 2015/16, copy attached, was submitted to the Trust Development Authority outlining the priorities for the year including: improving the quality and delivery of our urgent and emergency response; making the LAS a great place to work; improving our organisation and infrastructure; and developing the leadership and management capabilities within the LAS. The LAS Operating Plan 2015/16 also sets out the milestones towards meeting the operational performance standards; the measures relating to the workforce, including improving staff morale, reducing turnover, the recruitment of front line staff, and staff engagement; and the quality and safety priorities for the LAS will be assessed by the Care Quality Commission. Throughout the year the Trust Development Authority and NHS England will scrutinise the LAS’s achievement of the LAS’s Operating Plan and the investment agreed will be subject to meeting the milestones.
2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall.

The progress achieved in the recruitment programme is outlined in the report “Recruitment Progress” 15 May 2015. The recruitment summary sets out the position to recruit for recruiting paramedics nationally and internationally and recruiting Trainee Emergency Ambulance Crew staff (TEACs). The operational staff trajectory indicates that by October 2015 the LAS is aiming to recruit to a target establishment of 3004 front line staff which provides a vacancy rate of 5% to be covered by staff working overtime.

3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding; (a) I heard from the consultant Gynaecologist that all women of childbearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;

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To inform our decision about the introduction of pregnancy testing the Medical Director approached all of the Ambulance Service Medical Directors to ascertain if and where pregnancy testing was undertaken in the pre-hospital environment. The overwhelming response was that pregnancy testing was not undertaken by other ambulance services routinely with the exception of a small number of advanced trained practitioners in Wales. As indicated the Regulation 28 Report was shared with the National Ambulance Service Medical Directors’ Group (NASMeD) and the Chair confirmed that the national guidance for ambulance staff with regard to the assessment of women of child bearing age would be reviewed and any recommendations for change in the future would be considered and discussed by NASMed.

The Medical Director also asked the Consultant Midwife to offer her clinical opinion on ectopic pregnancy. The Consultant Midwife wrote:

In the pre-hospital setting: It is reasonable to assume that any woman of reproductive age (8-60 years) could be pregnant. This is based on the evidence that early menarche has been observed in population studies associated with improved nutrition, and at the later end of the menarche with the oldest spontaneous conception occurring at age 59 years. The Office of National Statistics (2011) detailed below highlight the age group classification for maternal age at birth per 1,000 deliveries, the births reported above 44 years of age are incorporated into the 40-44 grouping, but support the above assumption in that with their reported ranges from 15 to 44 years. With women now seeking artificial methods for pregnancy, both within and outside of the UK, the possibility of pregnancy at extremes of age must be assumed when a woman presents with symptoms that could be pregnancy related.

The guideline development group (GDC) from the National Institute for Health and Care Excellence (2014) agree that because of a wide range of symptoms associated with ectopic pregnancy, including non-specific symptoms such as gastro-intestinal symptoms, it is appropriate that healthcare professionals providing care for this group should have access to pregnancy tests and enable timely referral.

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NICE (2014) recommend that women who are haemodynamically unstable should be referred directly to an Emergency Department (ED), the London Ambulance Service would recommend this management in the first instance, and do not currently have the facility to undertake rapid diagnostic assessment of beta human chorionic-gonadotropin (B-HCG) to ascertain the presence of a pregnancy in this group of women without the potential for delay on scene.

The current methods for ascertaining pregnancy involve the use of urinary measurement of b-HCG, which would rely on a woman to be well enough to pass urine, and a period of 3-5 minutes for a result to be realised for the crew on scene. The benefit that this would afford would be that where symptoms were present and pregnancy was confirmed that an early pregnancy pathway could be utilised for the woman enhancing consultation with a gynaecologist in the first instance rather than via the ED. The undertaking of an on-scene test would add a potential delay in conveyance in the first instance and may not be possible where the woman was unwell and requires immediate conveyance.

The ideal solution would be a “near patient” test diagnostic solution where a small blood sample could be used to provide a confirmation en-route so there is not delay to conveyance but ensured the woman was seen in the right place, that of either the ED or an early pregnancy unit where further testing could be undertaken.

After careful consideration of the Consultant Midwife’s clinical opinion, the feedback from other ambulance services, and mindful of the potential impact on response times and the capacity to undertake the necessary training, the Medical Director of the LAS concluded that in the immediate future the LAS would not be in a position to introduce pregnancy testing. Providing appropriate training, quality assurance, infection control and disposal of body waste would present significant difficulty if pregnancy testing was introduced in the pre- hospital setting. Further the management of the patient who was unexpectedly found to have a positive pregnancy test was currently outside of the practice of a paramedic; conversely some patients may be given false reassurance from a negative test.

(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;

The advice from the Medical Directorate in the Clinical Routine Information Bulletin to be issued on 26 May 2015 to all staff is given below.

Staff are reminded that are a range of options to consider when there are challenges removing a patient from scene, this includes where it is not appropriate for the carry chair to be used either due to the clinical presentation of the patient or physical difficulties in using the carry chair. Additional resources can be requested via EOC to provide additional hands to help carry a patient. Further options include the use of the carry sheet, the use of the spinal board and straps. There is also specialist additional lifting equipment carried by both Hazardous Area Response Team (HART) and the advanced paramedic practitioners (APPs). A carry sheet should be carried on every frontline ambulance as per the current stocking lists these are single use and are available to order via the electronic procurement system (EPROC).

(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant

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points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed.

A copy of the case study entitled “Learning from Experience” in the mandatory Core Skills refresher training programme 2015. 1 is attached. The case study covers ectopic pregnancy, hypovolaemia, and fluctuating capacity. Also attached is a copy of the achievement record identifying the learner outcomes and objectives completed by the tutor and “student”. As at the 19 May 2015 347 staff (11% of operational staff) had completed the Core Skills refresher training programme, and the remainder of operational staff are expected to complete their training by 3 July 2015.

(4) The potential for systems improvements, such as automated re-categorisation, clinical re- triaging and feedback to call handlers regarding current timeframes were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS.

The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS implements its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.

The Clinical Hub has refined and developed its processes, skill mix and staffing levels since its inception on 2 December 2013 and an increased level of staffing within the Clinical Hub in the Emergency Operations Centres has negated the need for any automated processes. Staff have clear standard operating procedures in place for the management of Held call, vulnerable patients and calls being held awaiting assessment. The demand management plan itself has been reviewed and replaced with the surge management plan, which has a number of criteria for allowing progression through the plan and a scored matrix to evidence and inform any decision made.

The LAS has considered a facility whereby call handlers have real-time information relating to current waiting times for patients. This process is currently being reviewed by the Management Information and Governance Committees within the Trust for accuracy, appropriateness and suitability in a dynamically fast changing environment. It is essential that this is given careful consideration so that the most accurate information is passed on to patients, without having any detrimental impact on them, their carers or their 3rd party informants.

5) The potential for an ‘early warning score’ system, which is specifically validated for pre- hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view.

As with the introduction of pregnancy testing the Medical Director sought the views of National Ambulance Service Medical Directors’ Group (NASMeD) at their meeting on 21 April 2015 on the use of a national early warning score (NEWS) system in the pre-hospital environment to inform our assessment of the feasibility of introducing an early warning score

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system in London. The Chair of NASMed confirmed that while the NEWS system was recently approved for pre hospital use, and is used by Yorkshire Ambulance Service, there would need to be a discussion with the both the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and then NASMeD on whether the system could be recommended for use nationally or cited as an example of such a scoring system. There is currently no evidence on how applicable or sensitive NEWS scoring would be in the cases of gynaecological or obstetric collapse. Therefore the Medical Director of the LAS is reviewing the possibility of introducing NEWS scoring with the understanding it is more sensitive for conditions like sepsis.

(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations. Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain. It is clear that the Trust are taking further steps to address this; however, more detailed information as to timeframes and progress in this regard are required.

The governance processes relating to serious incident investigations are outlined in the Serious Incident Policy and Procedure, TP/006 most recently updated on 1 April 2015. The Serious Incident Policy and Procedure sets out the responsibilities from the Trust Board, to the Quality Governance Committee, individual directors and senior managers, and management groups in the LAS, as well as and all members of staff for reporting incidents, for investigating serious incidents, and taking action to reduce the risk of recurrence and / or mitigate the harm that may be caused. The Quality Governance Committee, which meets quarterly, has had and will continue to have a key role in seeking an assurance that the processes in the Serious Incident Policy and Procedure are being complied with and are robust; that incidents are being reported appropriately and identified as serious incidents; that when serious incidents are declared by the Serious Incident Group the root causes are identified and investigated; that lessons are being learned and actions are monitored and completed. The minutes of the Quality Governance Committee evidence that improvements in the timeliness in which investigations are completed are being monitored and that the Director of Corporate Affairs and Head of Governance and Assurance have been asked to provide further assurance as to the processes for ensuring that a thorough investigation is completed which is approved by a member of the Senior Management Team and a director from the Executive Management Team. The Procedure for Responding to Enquiries and giving evidence at Coroners Inquests and statements at Police interviews, TP/015, most recently updated and submitted to the Senior Management Team for approval on 27 May 2015 also states that staff who provide statements for a serious incident investigation and to the Coroner for an inquest receive feedback from the serious incident investigation and a copy of the serious incident investigation report.

In addition to seeking an assurance that the Serious Incident Policy and Procedure is being complied with the Quality Governance Committee will also be seeking an assurance that the statutory duty of candour is being complied with for notifiable safety incidents which include a broader range of incidents than those captured by the serious incident criteria.

A copy of the Serious Incident Policy and Procedure, the draft Procedure for Responding to Enquiries and giving evidence at Coroners Inquests and statements at Police interviews, TP/015, and Duty of Candour Policy are enclosed with this reply.

I hope that you and indeed Sabrina’s family will be reassured by the actions the LAS has taken and will continue to take to address your concerns.

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Dear Mr Brittain, REGULATION 28: REPORT TO PREVENT FUTURE DEATHS – Sabrina Stevenson Thank you for your report dated on 30 March 2015, relating to the following matter of concern: “Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be free up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.”

I would like to offer my sincere apologies for not meeting your deadline of 25 May. The duties that NHS England has in relation to LAS are:  Assurance of the CCG in respect of their commissioning arrangements, including contract management, quality oversight and delivery of national standards;  Direct oversight of LAS in respect of their emergency planning and resilience planning and capability.

NHS England also leads on generic system resilience in London, in which LAS is a lead provider.

During 2014, LAS found operational delivery against national standards increasingly challenged. NHS England together with Brent CCG (who commissions LAS services on behalf of London’s 32 CCGs), the NHS Trust Development Agency (TDA) and

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LAS undertook a number of steps to ensure the service remained resilient, safe and to secure improved ambulance response times in 2015. I will cover each step in turn:

1. Operational resilience

Operational performance was reviewed weekly by TDA, Brent CCG and ourselves throughout the winter of 2014/15. These reviews resulted in agreed additional actions to ensure the LAS could respond as effectively as it could within the ambulance resource available. Response times for Category A incidents has been improving since December 2014 and the LAS are meeting the agreed improved performance target.

NHS England, London Region and TDA also commissioned a diagnostic review of the key drivers of underperformance. The key findings were that utilisation of the service had increased significantly so impacting on the operational capability of the service. Utilisation levels are driven by the number of Category A incidents, the job cycle time and the number of vehicle hours. During the last year, the level of Category A incidents had risen and available vehicle hours had reduced and the nominal net turnover rate was rising. The requirement to reduce utilisation rates became a key objective for securing medium and long term resilience of the service. The business case agreed by London CCGs and the TDA aims to improve ambulance response times on a sustainable basis by reducing vehicle utilisation to optimal levels. As requested, further details of the business case investment are provided below.

2. External Clinical Review

During 2014, Serious Incidents (SIs) and complaints also rose. Although the causes of these were unclear; there was evidence that an increased focus on clinical risk management systems in the LAS and increased awareness of SIs could be contributory causes. In December 2014, NHS England commissioned an external clinical review of the London Ambulance Service (LAS) to assess the adequacy of LAS clinical risk management systems, deployed in the context of a significant vacancy position and rising service demand. This involved a multi-professional Clinical Review Panel, including members with Urgent and Emergency Care Systems expertise from London, outside London and LAS members. The panel was chaired by National Clinical Director for Urgent Care, NHS England. The purpose of the review was to assess the adequacy of the clinical risk management systems that the Trust has deployed. The review also considered those actions that could be put in place immediately (December 2014 through January 2015) and those medium to long term actions that could strengthen clinical risk management within LAS by:  Reviewing LAS corporate clinical governance/risk management arrangements

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 Specifically including a review of the Control Room and Hub; choices made at call taking outside the Advanced Medical Priority Dispatch System (AMPDS), alternative transport options and how those decisions are made  Making recommendations to the London Regional Director of NHS England for what could be put in place within LAS to further mitigate clinical risk.

The final report from the Review Panel was published on 17 December 2014. It found that the current governance structures and risk management processes supporting the day-to-day management and escalation of risks at the LAS, appeared robust, but made a number of recommendations to improve the management of risk. An overview group including NHS England, TDA, LAS and Brent CCG was formed. The Group agreed to accept all the recommendations. There is a delivery plan to ensure the implementation of the recommendations. This plan is reviewed by NHS England LAS Oversight Group on a quarterly basis chaired by the Chief Operating Officer for NHS England London Region.

3. Investment business case and NHS contract for LAS in 2015/16 NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG. The LAS contract for 2015/16 includes agreed improved performance and lower utilisation standards by month from May 2015. Performance is planned to meet the national standard in September and exceed the standard from November. These performance indicators are reviewed monthly by the LAS Contracts and Performance Group. For April and May, the LAS have performed above the agreed ambulance response time standard. The additional money will be spent increasing staffing and capacity to help better manage peaks in demand and to reduce utilisation rates so that the national standard of 75% of Category A calls being met within 8 minutes is achieved from September 2015. A total of 850 staff will be recruited in 2015/16. This includes around 150 new posts. Investment will also cover new ambulance vehicles and specialist clinical teams in the clinical hub to support GP and primary care referrals.

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The agreed improvement programme also includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital. I was very sorry to learn of the death of Sabrina Stevenson through your Regulation 28 report. I hope that my response has given you assurance that NHS England has taken sufficient steps to demonstrate that the risk of future deaths, from increasing response times, has been addressed.