“: 1”

The coroner’s concerns

: 1. Call Handling : I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given 6 additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call. 2. Training of Clinical Staff : I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff b providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created. 3. Conveyance Policy : The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a 7 series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment. 4. Data Gathering and Auditing : I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering. 5. Senior Management Awareness : I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other deaths. C. To : Joint Royal Colleges Ambulance Liaison Committee 8 The MATTER OF CONCERN is as follows : 1. I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC. In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place. D. To : (i) Mitie Care & Custody (Health) and (ii) Teesside University The MATTER OF CONCERN is as follows : 1. Although it was clear from the evidence that, as a provider of Forensic Medical Examiners to custodial settings, Mitie Care & Custody (Health) has in place thorough systems for the recruitment and monitoring of staff, I am concerned about aspects of the training currently being provided in relation to ED/ABD. I was told that this training is being delivered in conjunction with Teesside University and I was provided with a copy of the training materials. I am concerned about the following within the training materials : (a) Under the heading “What

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

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judiciary.uk, Prevention of Future Deaths reports, 2019-0095

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0