PFD report

Master Omarian Brooks · Prevention of Future Deaths report

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Issued 29 May 2020•Inner South London

Report record

Published report and response evidence

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.

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Concerns
2

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
23

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Dispute over hospital destination during ambulance transfer
    Part of recurring concern: Unreliable hospital destination selection for patient transfers
  2. Failure to inform the GP of patient deterioration
    Part of recurring concern: Failure to reliably notify primary care of changes affecting patient carePart of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
Responses linked to these concerns

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.6

  1. Action

    Offer Coordinate My Care plans to patients with complex medical needs to share treatment information with other services.

    Stated by and the Sydenham Green Group PracticeStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  2. Action

    Implement a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.

    Stated by and the Sydenham Green Group PracticeStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  3. Action

    Update the policy governing conveyance of patients to appropriate hospital destinations by the end of October 2020.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 June 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Conveyance to the nearest emergency department was indicated, and the crew acted correctly under policy.

    Stated by London Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Dispute over hospital destination during ambulance transfer

Wider context from the report

“2. There was also a distressing dispute between the ambulance crew and parents as to which hospital Omarian should be taken, in the event he was not taken to the nearest hospital at the insistence of his parents (although in this instance the delay was not found to have contributed to the death). ”

Is this part of a recurring concern?

Yes — Unreliable hospital destination selection for patient transfers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to inform the GP of patient deterioration

Wider context from the report

“1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after, he would have been admitted to hospital with a real prospect of the infection being successfully treated. ”

Is this part of a recurring concern?

Yes — Failure to reliably notify primary care of changes affecting patient care; Failure to reliably recognise and respond to acute clinical deterioration.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Offer Coordinate My Care plans to patients with complex medical needs to share treatment information with other services.

Verbatim wording from the response

“14. There were also lengthy discussions during the multi-agency meeting in respect of ‘Coordinate My Care’. This has been raised by other agencies as a way to have access to patient information from different agencies. The Practice has CMC embedded into their medical records system. The GPs have been using CMC regularly since its inception in 2015 for adult patients as a platform to share medical information with outside agencies such as London Ambulance Service, 111 and the local hospice. Unfortunately, the CMC was not available for children during the time of Omarian’s life. The GPs report that CMC is now available for children under the age of 18. The GPs have subsequently worked through CMC already with one family in the practice who have specific medical needs and will continue to offer it to all patients going forward.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 3 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.

Verbatim wording from the response

“4. The GPs have implemented a policy for circumstances where ‘rescue pack’ antibiotics are prescribed to patients with complex needs on a repeat basis. This policy includes an agreement which has to be made between the GPs and the parents. This agreement”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 1 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the policy governing conveyance of patients to appropriate hospital destinations by the end of October 2020.

Verbatim wording from the response

“The LAS’s position on conveying patients to the most appropriate destination is detailed in OP/014 Managing the Conveyance of Patients Policy and Procedure. During the inquest you were advised by Ms ████████, Sector Senior Clinical Lead, that this policy was due to be updated but due to the current pandemic it has not been possible for the LAS to carry out this update. The LAS endeavours to update this policy by the end of October 2020.”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish a position on information sharing and consistent identifiers for children to support professionals’ access to information and care coordination.

Verbatim wording from the response

“• The College has a published position on information sharing and maintains that having a unique, consistent identifier for children will allow professionals interacting with children to share information easily and provide better care for their needs.⁴”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue signposting and developing courses on communication issues, listening to parents, and patient-centred care for children with disability.

Verbatim wording from the response

“• Whilst we do not have all the details or specifics of the case, a breakdown in communication between the parents and health professionals involved in Omarian’s care may have occurred. The College will continue to signpost and develop courses that focus on ensuring awareness of communication issues in relation to children with disability, all of which emphasise the importance of listening to parents and of ensuring patient-centred care. We”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 1 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Bring together professional colleges to develop standards promoting connectivity, proactive care, and communication for children with ongoing health needs.

Verbatim wording from the response

“• In 2018, the College brought together the Royal College of General Practitioners, Royal College of Nursing, Royal College of Physicians and Royal College of Psychiatrists to develop Facing the Future: Standards for children with ongoing health needs³ to ensure connectivity between services, with a focus on improving long term care and management so that care is planned and proactive - particularly with improving communication and education for both the child and family, and communication between professionals.”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conveyance to the nearest emergency department was indicated, and the crew acted correctly under policy.

Verbatim wording from the response

“Given that this patient was presenting with a potentially critical illness, conveyance to the nearest emergency department was indicated. The acceptable exceptions to conveying the child to another hospital would not apply in an emergency situation for the nearest unit not being equipped to deal with a paediatric patient. This would not have been the case with Lewisham Hospital which has a paediatric emergency department.”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 10 June 2020

Open published response

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.17

  1. 1

    Audit the protocol for children who miss immunisations over a three-month period.

    Stated by and the Sydenham Green Group PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 June 2020.
  2. 2

    Establish quarterly practice meetings to discuss children aged 5–18 with complex medical needs outside existing multidisciplinary teams.

    Stated by and the Sydenham Green Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 10 June 2020.
  3. 3

    Allocate children with complex needs to named GPs, route correspondence to them, and maintain a shared register with record alerts.

    Stated by and the Sydenham Green Group PracticeStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  4. 4

    Audit vulnerable-family meetings over six months to assess whether agreed actions are implemented.

    Stated by and the Sydenham Green Group PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 June 2020.
  5. 5

    Provide other agencies with information about implemented practice changes through a multi-agency meeting.

    Stated by and the Sydenham Green Group PracticeStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  6. 6

    Establish a protocol for following up children on the emergency duty list when the GP cannot contact their parents that day.

    Stated by and the Sydenham Green Group PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 June 2020.
  7. 7

    Audit monthly that children with complex needs have been allocated named GPs.

    Stated by and the Sydenham Green Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2020.
  8. 8

    Clarify rescue-antibiotic arrangements with hospital or community consultants and require shared-care agreements.

    Stated by and the Sydenham Green Group PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 June 2020.
  9. 9

    Audit whether children with complex needs have parents identified and coded as carers.

    Stated by and the Sydenham Green Group PracticeStatus at responseThe respondent said that this action was partly complete when they made their response on 10 June 2020.
  10. 10

    Maintain a coordinated multi-agency approach for future patients.

    Stated by and the Sydenham Green Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 10 June 2020.
  11. 11

    Update the policy governing consent to examination or treatment by the end of October 2020.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 June 2020.
  12. 12

    Transition Patient Specific Protocol access to the Coordinate My Care system and require acute Trusts to review and transfer existing paper protocols.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  13. 13

    Coordinate an inter-agency meeting with Lewisham, Sydenham Green Group Practice and Lewisham & Greenwich NHS Trust representatives to address inter-agency working.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2020.
  14. 14

    Work with NHS England and the Royal College of Nursing to develop a systematic paediatric early warning system for recognising and responding to acutely ill or deteriorating children.

    Stated by Royal College of Paediatrics and Child HealthStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2020.
  15. 15

    Develop free paediatric sepsis podcasts as educational resources for health and social care professionals.

    Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  16. 16

    Develop toolkits with children and young people to raise awareness of hidden conditions and available support services.

    Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.
  17. 17

    Develop a framework with clinicians and experts to improve recognition and response to children at risk of deterioration.

    Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 10 June 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Coordinate My Care is the current and only system enabling the ambulance service to safely and effectively access patient-specific protocols.

    Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Patient-specific protocols must be written, renewed and updated by the patient's regular clinician, not the ambulance service.

    Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit the protocol for children who miss immunisations over a three-month period.

Verbatim wording from the response

“6.1 | A clear protocol in place for children who miss immunisations”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 9 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish quarterly practice meetings to discuss children aged 5–18 with complex medical needs outside existing multidisciplinary teams.

Verbatim wording from the response

“6. The GPs discussed during their meeting developing and putting in place a quarterly meeting to discuss children aged 5-18 with complex medical needs who are not discussed as part of the Health Visitor MDT aged 0-5 or the Palliative Care/Community MDT ages 18+. The GPs envisage that most of the Practice’s GPs attend this and each bring a small number of cases to be discussed. The GPs have scheduled to have a quarterly meeting in September 2020.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Allocate children with complex needs to named GPs, route correspondence to them, and maintain a shared register with record alerts.

Verbatim wording from the response

“7. As a result of Omarian’s death, all children who are coded as having complex needs have been allocated to a named GP. Therefore, any correspondence relating to these patients are to be brought to the attention of that named GP. In order to ensure that these patients have been allocated a named GP, the GPs are planning to undertake audits on a monthly basis to confirm this change has been implemented. The most recent audit to confirm the implementation took place on 8 July 2020 and is enclosed to this response. The named GP is also to consider discussing with the families of the children whether they should have a Coordinate My Care plan in place to share treatment plan with other services.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit vulnerable-family meetings over six months to assess whether agreed actions are implemented.

Verbatim wording from the response

“6.2 | An audit of vulnerable family meetings over a 6 month period to assess whether actions from the meetings are being taken. | | Practice Safeguarding lead | 6 months | Audit MDT HV (2).pdf | | GREEN”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 9 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide other agencies with information about implemented practice changes through a multi-agency meeting.

Verbatim wording from the response

“12. The Coroner comments in their PFD report under ‘Action Should Be Taken’ that “Accordingly these agencies and the local hospital are the subject of the report as in my opinion their joint action should be taken to prevent future deaths.” In light of the Coroner’s concerns, a multi-agency meeting took place on 14 July 2020. The purpose of the multi-agency meeting was to discuss the PFD Report and the concerns raised by the Coroner in order for a joint response to be prepared.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 3 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish a protocol for following up children on the emergency duty list when the GP cannot contact their parents that day.

Verbatim wording from the response

“6.4 | A clear protocol of following up on children on the emergency duty list where a GP is unable to make contact with parents on that day. | | Practice safeguarding lead | 3 MONTHS | | Protocol for emergency duty list.pdf | GREEN”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 9 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit monthly that children with complex needs have been allocated named GPs.

Verbatim wording from the response

“7. As a result of Omarian’s death, all children who are coded as having complex needs have been allocated to a named GP. Therefore, any correspondence relating to these patients are to be brought to the attention of that named GP. In order to ensure that these patients have been allocated a named GP, the GPs are planning to undertake audits on a monthly basis to confirm this change has been implemented. The most recent audit to confirm the implementation took place on 8 July 2020 and is enclosed to this response. The named GP is also to consider discussing with the families of the children whether they should have a Coordinate My Care plan in place to share treatment plan with other services.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Clarify rescue-antibiotic arrangements with hospital or community consultants and require shared-care agreements.

Verbatim wording from the response

“8. In situations where a GP receives a request for rescue antibiotics or similar from a hospital or Community Consultant, they are to clarify exactly what is being covered and ask the Consultant to send a shared care style agreement to formalise the arrangement.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit whether children with complex needs have parents identified and coded as carers.

Verbatim wording from the response

“9. Following the Practice Meeting a search for children with multiple complex needs was undertaken and identified eight children within the Practice. Further examination of their notes was undertaken to ensure that the code ‘has a carer’ was recorded, and then cross referenced with their registered parents/guardians so that in each of their notes, it was coded that they were ‘a carer’. Each child was then allocated a named GP. The GP was informed, and it was highlighted as an alert on the child’s records.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a coordinated multi-agency approach for future patients.

Verbatim wording from the response

“17. There were important discussions at the multi-agency meeting which were greatly beneficial for the GPs. It allowed for there to be discussions relating to how the Practice can implement changes and how other agencies can support those changes. The Learned Coroner will note that a multi-agency response has been formulated which gives an overview of how each agency has implemented their own changes and also how they are working together to ensure there is effective co-ordination between the different agencies. The GPs are committed to having a coordinated multi-agency approach to future patients.”

Source location

2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 4 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the policy governing consent to examination or treatment by the end of October 2020.

Verbatim wording from the response

“Furthermore, during the inquest you were also advised by Ms ████████ that the Policy for Consent to Examination or Treatment (OP/031) will be updated by herself. However, due to the current”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Transition Patient Specific Protocol access to the Coordinate My Care system and require acute Trusts to review and transfer existing paper protocols.

Verbatim wording from the response

“A ‘flag’ in the Emergency Operations Centre (EOC) mapping system was placed so if an emergency call was received by the LAS for that address a little note would come up to say there was a PSP. It was clear to the LAS that this system was not optimal for all of our patients so in collaboration with NHS England (NHSE) and NHS Improvement (NHSI) the LAS transitioned to use the Coordinate My Care (CMC) system for PSPs in 2019. Around February 2018 with the roll-out of iPads, the LAS wrote to acute Trusts in London to inform them that the practice of holding PSPs within our control room was going to be phased out within the next year due to the introduction of the CMC system. All Trusts were asked to review existing PSPs and transfer them to the CMC system.”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate an inter-agency meeting with Lewisham, Sydenham Green Group Practice and Lewisham & Greenwich NHS Trust representatives to address inter-agency working.

Verbatim wording from the response

“At the time of writing, the LAS’s legal services department has contacted the legal representatives of London Borough of Lewisham, Sydenham Green Group Practice and Lewisham & Greenwich NHS Trust to co-ordinate a meeting. It has been suggested that”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with NHS England and the Royal College of Nursing to develop a systematic paediatric early warning system for recognising and responding to acutely ill or deteriorating children.

Verbatim wording from the response

“• The College is also working with NHS England and the Royal College of Nursing to develop a systematic paediatric early warning system, to develop a consistent approach and common language to promptly recognise”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop free paediatric sepsis podcasts as educational resources for health and social care professionals.

Verbatim wording from the response

“• The College has also developed free to access paediatric sepsis podcasts that have been designed as educational resources for health and social care professionals. They explore what sepsis is, the complexities of how to recognise and manage sepsis, what is different about sepsis in children with complex health conditions and much more⁶.”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop toolkits with children and young people to raise awareness of hidden conditions and available support services.

Verbatim wording from the response

“have developed toolkits with children and young people with a hidden condition or illness to help raise awareness of conditions and support services².”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a framework with clinicians and experts to improve recognition and response to children at risk of deterioration.

Verbatim wording from the response

“• The College and NHS Improvement developed a framework with clinicians and experts to improve recognising and responding to children at risk of deterioration⁵. This was in response to research showing that failures to recognise and treat patients whose condition was deteriorating causes significant unintended harm.”

Source location

2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate My Care is the current and only system enabling the ambulance service to safely and effectively access patient-specific protocols.

Verbatim wording from the response

“A ‘flag’ in the Emergency Operations Centre (EOC) mapping system was placed so if an emergency call was received by the LAS for that address a little note would come up to say there was a PSP. It was clear to the LAS that this system was not optimal for all of our patients so in collaboration with NHS England (NHSE) and NHS Improvement (NHSI) the LAS transitioned to use the Coordinate My Care (CMC) system for PSPs in 2019. Around February 2018 with the roll-out of iPads, the LAS wrote to acute Trusts in London to inform them that the practice of holding PSPs within our control room was going to be phased out within the next year due to the introduction of the CMC system. All Trusts were asked to review existing PSPs and transfer them to the CMC system.”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Patient-specific protocols must be written, renewed and updated by the patient's regular clinician, not the ambulance service.

Verbatim wording from the response

“In 2017 the LAS was operating a PSP process which involved the patients’ regular clinician (GP or Hospital Consultant) completing paper forms detailing the specific clinical requirements that may be required for their patient’s condition. This form was faxed or emailed to the LAS, in order to provide supplemental information to the crews when attending the patient in an emergency. The PSP lasted for 1 year with the responsibility of renewing and updating it lying exclusively with the clinician who initially completed it. A PSP has never and can never be written by the LAS as this responsibility lies with the patients’ regular clinician.”

Source location

2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 2 · response
Published 10 June 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026