London Ambulance Service NHS Trust

“we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”

“we will expand the use of the SBAR handover tool for use in when such reports are provided. We are absolute that this enhanced process should not delay an early request for assistance where it is immediately apparent that such assistance is required but an SBAR should be provided once an initial assessment has occurred.”

“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”

“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”

“The LAS will be informing the HSIB about the inaccurate information that was fed into its report and will be providing the HSIB with details of the actions that the LAS has taken to avoid a recurrence of this.”

“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”

“During the afternoon of 29" January 2018 demand in the service was above that predicted and staffing levels both operationally and in the Clinical Hub were below the below the planned”

“The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester Triage System and with specific Clinical Hub training.”

“prison will continue to work with the healthcare provider f ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.”

“in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.”

“All London 111 providers will at times of likely significant delay defined by London Ambulance Service as”

“Additional scripting of condition specific additional information specifically in relation to type 1 diabetes has been raised as a result of this concern with the National NHS Pathways team for their consideration and response as a result.”

“the London Ambulance Service NHS Trust (LAS) have agreed a process with NHS 111 whereby clinicians from NHS 111 can alert the LAS Emergency Operations Control about the calls made to NHS 111 where there is a clinical concern. The electronic flagging system was introduced on 14 March 2016 following consultation with NHS 111.”

“am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has 2 been addressed.”

“I am concerned by evidence provided from LAS that there are 400 vacant 2 positions within the Trust. This connotes a significant recruitment issue for the profession, which could risk future deaths occurring simply through a lack of available trained paramedics”

“On 23 April 2015 I wrote to all LAS staff to inform them of the additional investment the LAS had secured.”