Anthony Offord

Coroner's concerns

AI summary

Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.

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(1) There is (apparently) no training given to Emergency Medical Dispatch staff as to signs of respiratory difficulty including the well known relevance of snoring in a person who cannot be roused. This may perhaps require an amendment to the breathing diagnostic tool? (2) That where crew make a unilateral decision to stand off there is no requirement for a manager to be informed, even when there is likely to be a delay in the provision of support.

(3) That there is no system to ensure that all alternative methods of support are automatically considered when a stand-off occurs, not simply a double crewed ambulance.

(4) Consideration might be given as to whether drivers could be provided for lone responders on late shifts. This would be similar to the system used by many ‘out of hours doctor’ services and would provide some security for the lone responder thus lessening the need for stand-offs.

(5) With some diffidence, the point should also be raised that apart from the other lone responders who were available, as referred to in ‘Circumstances of the Death’ above, there was another double crewed ambulance nearby which could very likely have reached the scene as early as 2310 -- a point at which Mr Offord might have been saved. Unfortunately at 2302 this vehicle had become 'unavailable out of meal break window'. I recognise that this is a difficult subject, with valid arguments on both sides. I appreciate that it is a national issue, much debated in the past, and I do no more here than record the position as regards that vehicle.

Responses

1 respondent

Yorkshire Ambulance Service NHs Trust NHS / Health Body

15 Oct 2014 PDF

Action Taken

Yorkshire Ambulance Service reviewed training for EMD staff, clarified management involvement in 'stand off' decisions, and reinforced consideration of alternative support methods. They are also reviewing the meal break policy to balance staff needs and patient safety, and have reminded staff about incident reporting procedures. (AI summary)

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Dear Sir Inquest touching the death of Mr: Anthony Offord (deceased) Response to Regulation 28 Report to Prevent Future Deaths dated 8 September 2014 Thank you for your report dated 8 September 2014, issued under paragraph 7_ Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 note that your report is addressed to the Secretary of State for Health in addition to me as Chief Executive of the Yorkshire Ambulance Service NHS Trust ("the Trust"). am aware that during the three inquest heard on 24,25 and 28 July 2014,you heard evidence about the actions taken by the Trust since Mr Offord's death to improve the systems and processes relevant to 'stand off' decisions. The purpose of this letter is to provide you with a full response to the concerns set out in your report of 8 September 2014, in so far as these are issues which can be addressed by the Trust on a regional basis_ appreciate that some of the concerns you raise are potential national issues and, where this is the case; will defer to others in terms of the appropriate response have responded to the concerns raised in your report in the order in which they appear namely: Training for Emergency Medical Dispatcher ("EMD") staff and possible amendment to the breathing diagnostic tool, The involvement of managers in 'stand off' decisions_ Consideration of all alternative methods of support in stand off cases; The possibility of providing drivers for lone workers on late shifts
5. Meal breaks Training for EMD staff and possible amendment to the_breathing diagnostic_tool Your concern: There is (apparently) no training given to Emergency Medical Dispatch staff as to signs of respiratory difficulty including the well-known relevance of snoring in & person who cannot be roused. This may perhaps require an amendment to the breathing diagnostic tool? Trust response: AII EMD's employed by the Trust undergo a robust training programme This includes the following: Corporate Induction which includes Basic Life Support training and use of Automated Emergency Defibrillator (AED) A one week course on the Advanced Medical Priority Dispatch System (AMPDS) followed by a two course on 'Medical' which is the triage tool used within the Emergency Operations Centre (EOC) with medical background information to support this_ An exam is undertaken at the end of day day

this course whereby a minimum pass mark of 85% must be achieved and a candidate cannot progress further without this. four week training course on the use of the Computer Aided Dispatch (CAD) system which is the system used within the EOC_ Exams are taken throughout the course followed by a final exam. Only those that pass the exams are able to progress onto mentorship stage. A six week mentorship programme in the live environment; followed again by a final written exam and assessment: AMPDS re-certification every 2 years including evidence of continued development. Specific training in relation to breathing difficulties is incorporated in the above programme and this particular element is heavily embedded in the triage tool: The AMPDS provides the call taker with information about ineffective and agonal breathing and how to recognise this breathing diagnostic tool is available to aid the EMD in making decisions about patient's breathing The breathing diagnostic tool (part of the AMPDS) is an internationally recognised and approved system used by Ambulance Services nationally: The Trust does not have the power to amend this system unilaterally and note that your report has been copied to the International Academy of Emergency Dispatch with a view to exploring this issue further. Within the Trust; a new Clinical Duty Manager (CDM) role was implemented within the EOC on July 2014. A part of the role is to actively 'floor walk' and listen in to calls to review for any changes in clinical condition _ This would enable the EMD staff member to seek clinical input into a call as required. The involvement of_managers_in 'stand off'_decisions Your concern: That where crew make a unilateral decision to stand off there is no requirement for a manager to be informed, even when there is likely to be a delay in the provision of support Trust response: The Trust is implementing a change in current practice within the EOC which is based around the Joint Decision Model (JDM). This is the standard decision decision making model used across the police service in the United Kingdom_ The model seeks to bring together the available information pertinent to the decision, reconcile objectives and then enable effective decisions to be made_ The model will be applied to a wide range of scenarios, but in a stand-off situation, there will be a manager actively reviewing, assessing and building intelligence within the EOC to be able to make decisions and provide the front line clinician with robust information in order to support them to make dynamic risk assessment of the situation. AIl Duty Managers within the EOC have undertaken a five training course in the model: The next phase of the rollout will be to provide all the CDMs and team leaders with the training All other staff within the EOC will be provided with an awareness session so they understand the changes that are place. This is a phased implementation of the model and is estimated to be completed by May
2015. Where there is concern for patient in stand off scenarios, these are escalated via a Team Leader to the Duty Manager within the EOC. The Duty Manager and the CDM are seated together in the EOC, this means they are able to work together effectively when incidents such as this occur, and together use the JDM model to provide additional intelligence to the attending crew to assist their decision making at scene All Red 1 and Red 2 incidents (whether this relates to a stand-off situation or not) where the estimated time of arrival is greater than the response are actively listened to by clinicians within the clinical hub Where these delays have been identified they are now escalated to a CDM for further clinical assessment: 14th key day taking the

Consideration ofalalternative methods of support in stand off cases Your concern: That there is no system to ensure that all alternative methods of support are automatically considered when a stand-off occurs; not simply a double crewed ambulance Trust response An information bulletin has been provided to all staff within the EOC to remind them to consider all alternative methods of support in a stand-off situation, including all forms f responders, not just double crewed ambulances, and also, where applicable; other emergency services, such as the The implementation of the JDM and the improved escalation processes, as described above, will also ensure that all alternative methods of support are considered_ The_possibility of_providing drivers for lone workers on late shifts Your concern: Consideration might be given as to whether drivers could be_provided for Ione responders on late shifts: This would be similar to the system used by many 'out of hours doctor' services and would provide some security for the Ione responder thus lessening the need for stand- offs_ Trust response: The above concern has been noted within the Trust. The Trust's Accident and Emergency Operations Workforce Model is based on the resources currently available in terms of the number of different response vehicles_ These response vehicles consist of both lone worker and double crewed resources To implement a system suggested would require significant numbers of extra staff across the region or alternatively; in the absence of additional staff , would lead to many responder vehicles being unused_ This would not be practicable or manageable on the basis of current resources funding arrangements The introduction of additional funding to enable such a system to be implemented is not within the powers of the Trust: The Trust has, however; reviewed and updated the Safety and Security Policy, which covers the process relevant to lone responding: Training and education about the dynamic risk assessment process for frontline responders has been strengthened and awareness about the JDM being implemented in EOC is planned prior to its implementation. Using the JDM will ensure a standardised framework is utilised for all stand-off decisions. Where stand off decisions are made will be based on dynamic assessment relating to that individual incident with appropriate escalation as required. Meal breaks Your concern: With some diffidence; the point should also be raised that apart from the other lone responders who were available, as referred to in 'Circumstances of the Death' above, there was another double crewed ambulance nearby which could very likely have reached the scene as early as 2310 a point at which Mr Offord might have been saved: Unfortunately at 2302 this vehicle had become 'unavailable out of meal break window' recognise that this is a difficult subject; with valid arguments on both sides: appreciate that it is a national issue, much debated in the past; and do no more here than record the position as regards that vehicle. police. and they

Trust response: The Trust is continuing to review the meal break policy to ensure it meets the needs of both staff and patients in order to provide a safe, effective and quality service. Additional matters am aware that you raised a concern during the inquest hearing, which is also referred to in your report; regarding incident reporting within the Trust take this opportunity to confirm that alerts have been issued to staff to remind them of the importance of incident reporting and detailing what constitutes an incident; near miss or issuelconcern. From June 2014 the internal incident reporting line has run on a 24/7 basis to make it easier for staff to report incidents. Staff have been reminded, by way of an alert issued in August 2014, to specifically report any delays in response which they believe may have resulted in harm to a patient; hope that this letter provides you; and Mr Offord's family; with assurance that the Trust has taken this case extremely seriously; has carefully considered the concerns raised in your report and taken steps to improve the quality of the service the Trust provides to patients. can provide any further information to you please do not hesitate t0 contact me Yours atthfullv David Whiting Chief Executive Officer Yorkshire Ambulance NHS Trust [Cc Secretary of State for Health and the cc recipients of the Coroner's original report dated
8.9.14]

Report sections

Investigation and inquest

On 19th April 2013 I commenced an investigation into the death of Anthony Offord (aged
35). The investigation concluded at the end of the inquest on 20 August 2014. The narrative conclusion of the inquest was that Mr Anthony Offord died at the Northern General Hospital, Sheffield on the 18th April 2013 in consequence of anoxia sustained in an incident at Harcourt Road, Sheffield two days earlier, following the consumption of a small amount of morphine and a more significant amount of alcohol. An ambulance had been called at the time but the lone responder attending (who arrived nearby very quickly) felt the need to stand off until support was available on the grounds of personal safety. The double crewed vehicle nominated to back up the lone responder was some distance away. There was a failure to consider other methods of support for the lone paramedic during that period but it cannot be said on the balance of probabilities that Mr Offord would have survived if any of the opportunities for alternative support had been taken.

Circumstances of the death

Anthony Offord collapsed at a friend's flat on the edge of Sheffield city centre at approximately 23.00 on 16 April 2013. An ambulance call was made at 23.01 which was categorised as a 'Red 2'. At approximately 23.06 a lone responder (an Emergency Care practitioner or ECP) arrived near to the flat but for reasons of personal safety decided to stand off until supported. The inquest did not seek to criticise or support the ECP's decision to stand off, it was made on a proper consideration of all known circumstances. One piece of information given to her by a colleague was ill-considered but the ECP would not have known this. The matters of concern in this report do not arise from the actual decision by the ECP but rather from the actions/inactions of those in the Operations Centre following that decision. In making the decision to stand-off the ECP had enquired of the Emergency Operations Dispatcher (EOD) in the Operations Centre "just wondering whether there was anyone else available to go with me". There was no enquiry made as to exactly what was meant by this nor further discussion on the point. The ECP made clear in her evidence that in fact she would have been perfectly content to enter the premises with another lone responder or a single police officer. A double crewed ambulance became available at 23.08 and was allocated to support the paramedic but this was on the outskirts of the city with an ETA of 23.24, that is a further 16 minutes delay. There was no thought within the Operations Centre as to alternative support for the ECP other than a double crewed ambulance, the lengthy delay was simply accepted without question. Scrutiny at the request of the inquest revealed that there had been two other lone responders available in the area, both of whom would probably have reached the scene by 23.15. Reference to a further vehicle, albeit in rather different circumstances, is made at point 5(e) below. Nor was any enquiry made of the police as to support. The city centre police station is within 1.5 miles of the scene and the city centre itself slightly closer. The evidence at the inquest made plain that requests to the police for assistance before entering are common and both paramedics who gave evidence said that in their experience they would be involved in such a situation about once a month. Notwithstanding the evident delay in this Red 2 category call, the EOD did not involve a manager—and I understand that there was no protocol requiring her to do so. In fact Yorkshire Ambulance Service management did not learn of the stand-off or the delay in this case until the family of the deceased raised concerns with my office. The double crewed ambulance arrived on scene at 2323 and entry was made within a minute or so thereafter. Mr Offord had by then sustained such a degree of anoxia that he died from his hypoxic brain injury two days later. In fairness, it should be clear that despite careful analysis of expert evidence the inquest could not be satisfied on the balance of probabilities that Mr Offord would have survived if the alternative sources of support for the lone paramedic had been utilised. My concern in this report is for other cases in the future. Finally, it should also be explained as a separate issue that throughout this time the Emergency Medical Dispatcher (EMD, in practice the call handler) remained on the telephone to those in the flat. The breathing diagnostic tool was used on more than one occasion and the recording of the call shows that at times Mr Offord's breathing (or grunting, gasping etc) was plainly audible. In fact the EMD asked at one point whether the noise he could he hear was Mr Offord breathing. On two occasions those in the flat make reference to Mr Offord snoring. In evidence the EMD said that he had never received instruction on the various sounds of breathing, and was not aware that a snoring sound from a person who was unable to be roused was likely to indicate the potentially fatal obstruction of breathing. Nor was he aware that snoring is commonly a late sign in those whose unconscious state is caused by drug overdose.

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