This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 29th November 2022 an investigation was commenced into the death of Claire Nicole Briggs, aged 42 years. The investigation concluded at the end of the inquest on 12th July 2023. The conclusion of the inquest was that she died of a propranolol overdose on 28th November 2022 at Stepping Hill Hospital, Stockport, having taken approximately ████████ propranolol tablets from previous prescriptions. She declined to be taken to hospital by the police for the critical time period after she had taken the tablets. There were 2 admitted failings by the North West Ambulance Service effectively to conduct clinical reviews of the incident which were not in themselves causative of her death, but the combined effect of those failings, the absence of any method within the NHS Pathways system to identify high risk overdoses and the pressures on the deployment of ambulances on that day combined to lead to a delay in her arrival at hospital which possibly contributed to her death.
Circumstances of the death
Claire Briggs was first prescribed propranolol from 2008 and had been regularly ████████ prescribed daily doses of that medication since 2019.
████████████████████████████████████████████████████████████████████████████████████████. I found, on the evidence, that she had consumed approximately ████████ propranolol tablets.
A friend and the police attended at her home quickly. Ms Briggs was resistant to be taken to hospital until the time at which the effects of the ingestion of drugs became evident. Notwithstanding her stance, the police officers and others at the scene made repeated calls to the ambulance service. In total, 9 calls were made between 4.37pm and 6.12pm, 6 of which were made prior to Ms Briggs relenting and accepting that she should be taken to hospital and a further separate call by the police to the Hear and Treat helpline. The evidence I heard was that calls made by police officers from the scene to NWAS are triaged in the same way as other 999 calls.
The ambulance service call handlers used the NHS Pathway process in dealing with each of the calls, which prompted a response category under the NHS Pathway system which resulted in a Category 3 response, which was not upgraded to Category 2 until a call made at 17.53 and the incident was prioritised at 18.16 so that the next available ambulance was allocated to respond.
There were significant delays within the ambulance service at that time, such that national target response times were significantly breached.
Prior to the arrival of the ambulance and in light of Ms Brigg’s obviously deteriorating condition and the uncertainty over the arrival time of the ambulance, the police officers decided to transport her to hospital themselves by police vehicle, but she experienced seizures before the police car left the vicinity of her address, which as closely followed by the arrival of the ambulance at 18.32. The police officers at the scene, in the calls they made from the scene and through their control room were unable to convey the seriousness of Ms Brigg’s condition to the ambulance service.
She went into cardiac arrest at the scene in the back of the ambulance and was subsequently taken to hospital, where, despite care and treatment under guidance from a senior member of the National Poisons Advice Service, she died.
The ambulance service accepted that there were failures to undertake timely clinical reviews of the incident.
Coroner’s concerns
The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised2
Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.26
Action
Oversee progress updates on Joint Operating Protocol implementation through the Regional Clinical Quality Assurance Committee.
Stated byNHS Cheshire and Merseyside ICBStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Implement and operate Joint Operating Protocols with four North West police forces covering information sharing, agency primacy, escalation, open lines, lead agency and clinical hub contact.
Stated byNHS Cheshire and Merseyside ICBStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Review the concerns with two other Northwest integrated care boards and coordinate steps to progress them.
Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.
Stated byNorth West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Complete sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.
Stated byNorth West Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Review communication procedures and standards with blue-light partners, particularly North West Ambulance Service.
Stated byMerseyside Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.
Stated byGreater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.
Stated byGreater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Develop a Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.
Stated byGreater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Maintain agreed police–ambulance escalation processes for obtaining information, escalating delays, cancelling ambulances and resolving operational concerns.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Provide frontline personnel with access to NWAS remote clinical support through SOPs and fallback telephones.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Continue adopting JESIP principles and operational guidance to promote collaborative working between blue-light partners.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Apply JESIP principles and clear speech when coordinating with other emergency services.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Provide feedback to NWAS and conduct a gap analysis of information-sharing procedures against NWFC operating arrangements.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Embed and assess compliance with NFCC National Operational Guidance and JESIP inter-agency operating standards.
Stated byNorth West Fire ControlStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Operate the Multi-Agency Tactical Control Communications Group to improve interoperability through shared lessons, training and exercises.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Adopt Multi-Agency Incident Transfer as an early adopter and put the tool in place.
Stated byNorth West Fire ControlStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Provide officers with clinical support through the “treat and hear” facility for direct updates from NWAS.
Stated byCumbria ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.
Stated byCumbria ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Sign and endorse the revised joint operating protocol.
Stated byCheshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Provide control-room briefings to support exchange of initial triage information with partner responder agencies.
Stated byBritish Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Maintain direct inter-control-room communications with police, ambulance and fire services through ESICTRL talk groups.
Stated byBritish Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.
Stated byLancashire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).
Stated byLancashire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.
Stated byLancashire ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.
Stated byLancashire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4
Position
Existing GMP-NWAS escalation processes are considered appropriate and sufficient while work continues to implement the Joint Operating Procedure.
Stated byGreater Manchester PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.
Stated byGreater Manchester PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing LFRS guidance and processes are considered sufficient to address the recommendations.
Stated byLancashire Fire and Rescue ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.
Stated byLancashire ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.36
1
Monitor key learning points and recommendations to ensure they become embedded in practice.
Present and share the Regulation 28 report and response with the Greater Manchester System Quality Group to support incorporation of learning into commissioned services.
Increase ambulance capacity by growing the workforce.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
4
Expand new community services to support urgent and emergency care recovery.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
5
Issue national ambulance-service guidance requiring further intervention or automatic upgrading of declared overdose cases within 30 minutes.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
6
Speed hospital discharges to support urgent and emergency care recovery.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
7
Introduce a distinct NHS Pathways disposition code to identify overdose and suicide-risk cases for clinical advisors.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
8
Improve ambulance response times through the urgent and emergency care recovery plan.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
9
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
10
Mandate robust clinical oversight in ambulance control rooms for self-harm and suicidal patients.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
11
Update overdose guidance to apply the clinical-oversight process to Category 5 overdose, accidental-ingestion and potential-suicide contacts.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
12
Address unwarranted performance variation in the most challenged local systems.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
13
Engage British Transport Police, North West Fire Control and regional Fire and Rescue Services to extend the Joint Operating Protocol to additional partner agencies.
Stated byNorth West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
14
Develop a process for ambulance-service escalation to the GMP dispatch duty inspector before referral to the Force Duty Officer.
Stated byGreater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
15
Hold weekly senior meetings with NWAS and Greater Manchester Fire and Rescue Service to discuss demand and operational issues.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
16
Collate daily data on police–ambulance delays and report it to FCCO senior leadership weekly.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
17
Relaunch and communicate the Hear and Treat service to GMP officers and staff through the Force intranet.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
18
Train and assess all operational personnel in immediate emergency care under external clinical governance.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
19
Apply a defined process for exceptional casualty transportation, including clinical consultation, risk assessment and duty-officer authorisation.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
20
Provide the ERAL resilient radio network as a preferred backup communication mode for emergency interoperability.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
21
Maintain and regularly test the tri-service communication link between emergency service control rooms.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
22
Incorporate NFCC National Operational Guidance into standard operating procedures.
Stated byLancashire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
23
Test inter-agency communication channels daily and through real-life incidents and exercises.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
24
Support partner fire services by enabling access to the NWAS Trauma Cell for clinical advice during ambulance delays.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
25
Establish a multi-agency control-room forum with clear terms of reference.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
26
Secure funding and appoint a temporary Inter-Agency Liaison Lead to strengthen multi-agency working.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
27
Coordinate multi-agency training and exercising to test mobilisation and responses, including major incidents.
Stated byNorth West Fire ControlStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
28
Share the response with partner fire and rescue services to disseminate identified lessons.
Stated byNorth West Fire ControlStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
29
Implement and review recommendations arising from the Manchester Arena Inquiry.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
30
Work with the four fire and rescue services to understand the impact of Right Care, Right Person on call handling.
Stated byNorth West Fire ControlStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
31
Establish a framework to identify inter-agency performance shortfalls and feed them into improvement and multi-agency processes.
Stated byNorth West Fire ControlStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
32
Update standard radio procedures to incorporate NWAS triage requirements and communicate casualty seriousness.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
33
Establish an Organisation Improvement Team to support audit and assurance.
Stated byNorth West Fire ControlStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
34
Establish and sign a regional Information Sharing Agreement with NWAS and regional police forces.
Stated byCumbria ConstabularyStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
35
Disseminate Ten Second Triage learning to officers through Lessons Exploitation Centre weekly bulletins.
Stated byBritish Transport PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
36
Deliver Ten Second Triage training through annual First Aid refresher sessions.
Stated byBritish Transport PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3
1
Existing national overdose guidance and ambulance clinical-oversight requirements are considered sufficient to address identification and escalation of high-risk overdose calls.
Stated byNHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
2
Existing casualty communication, monitoring and escalation arrangements are considered sufficient to prevent deaths arising from the identified circumstances.
Stated byMerseyside Fire and Rescue ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
3
NWAS is the lead agency responsible for developing the Joint Operating Procedure.
Stated byGreater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Information checked against the published report and official responses