Maternity pre-arrival instructions by 999 call handlers

The Healthcare Safety Investigation Branch’s National Report recommended that the Department of Health and Social Care identifies a suitable regulatory mechanism to provide formal oversight of 999 maternity pre-arrival instructions (PAIs) across NHS-funded care in England. The Department of Health and Social Care accepts this recommendation. The formulation of PAIs forms part of the clinical governance framework that is in place with the triage system provider; oversight of the clinical content rests with the triage system provider, and ambulance services are responsible for ensuring these PAIs are issued in response to appropriate remote triage. Following any NICE recommendations, NHSEI will ensure rollout of agreed consistent clinical guidelines. Alongside its role in determining the priority category assigned to 999 calls, there is also a role for Emergency Call Prioritisation Advisory Group (ECPAG) in ensuring that developments and changes to PAIs are both suitable for the remote advice situation but also consistent with current guidance, including from NICE and the Royal Colleges. ECPAG approved amendments to its Terms of Reference (ToR) to reflect the additional oversight required of PAIs going forwards. The ToR now include ECPAG putting in place a formal review process for the implementation and ongoing monitoring of the PAIs, following on from recommendations to PAIs being made and implemented. ECPAG will review information on any SIs or other concerns regarding maternity PAIs. Any suggested amendments will be taken forward through an agreed change process (to be determined through development of NICE guidance). Actions planned to deliver safety recommendation: ECPAG has formally accepted and amended its ToR to reflect the additional oversight required of PAIs going forwards. NHSEI will provide regulatory oversight through their involvement in the agreed process and will require ambulance trusts to adopt system updates. By: ASAP. Other dependencies identified: ECPAG will review information on any SIs or other concerns regarding maternity PAIs. Any suggested amendments will be taken forward through an agreed change process (to be determined through development of NICE guidance (as per HSIB rec R/2022/180). Additional comments: ECPAG will put in place a formal review process for the implementation and ongoing monitoring of the PAIs, following on from recommendations to PAIs being made and implemented. Ambulance services will feed learning from service level reviews of incidents into the AACE Quality Improvement, Governance and Risk Directors (QIGARD). Where issues are identified, they will be escalated upwards for review and any actions incorporated into ambulance services systems. Response received on 24 June 2022.

We have reviewed our Patient Safety Incident Investigation (PSII) standards alongside all Patient Safety Incident Response Framework documentation. Our review included consideration of the recommendation raised by the HSIB in this report as well as feedback from our independent evaluation of our PSIRF early adopter programme. We have implemented the recommended change and look forward to publishing the revised documentation in June 2022. Response received on 20 April 2022.