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Investigation Into Staffordshire Ambulance Service NHS Trust April 2008

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Investigation Into Staffordshire Ambulance Service NHS Trust April 2008 Investigation Investigation into Staffordshire Ambulance Service NHS Trust April 2008 Inspecting Informing Improving © 2008 Commission for Healthcare Audit and Inspection. This document may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the document title and © Commission for Healthcare Audit and Inspection 2008. Concordat gateway number: 122 ISBN: 978-1-84562-181-0 Contents The Healthcare Commission 2 Summary 3 Introduction 11 National context 14 Local context 16 The management of medicines 19 The process for introducing new equipment 37 The management of community first responders42 The management of staff, and training and education 50 Clinical governance and the management of risk 60 Leadership and management 69 Joint working arrangements with local health community partners 77 Conclusions 82 Developments since the investigation was announced 87 Recommendations 88 Appendix A: The Healthcare Commission’s criteria for an NHS investigation 90 Appendix B: The investigation team 91 Appendix C: Interviews 92 Appendix D: Sources of information 94 Appendix E: List of parenteral medicines that can be administered by paramedics 96 for the immediate necessary treatment of sick or injured persons Investigation into Staffordshire Ambulance Service NHS Trust 1 The Healthcare Commission The Healthcare Commission’s full name is the Investigating serious failings in Commission for Healthcare Audit and healthcare Inspection. We exist to promote improvements in the quality of healthcare and public health The Healthcare Commission is empowered by in England. We are committed to making a section 52(1) of the Health and Social Care real difference to the provision of healthcare (Community Health and Standards) Act 2003 to and to promoting continuous improvement for conduct investigations into the provision of the benefit of patients and the public. healthcare by or for an English NHS body. The Healthcare Commission was created We will usually investigate when allegations of under the Health and Social Care (Community serious failings are raised, particularly when Health and Standards) Act 2003. The there are concerns about the safety of organisation has a range of new functions and patients. Our criteria for deciding whether to took over some responsibilities from other conduct an investigation are set out in commissions. We: appendix A. • have replaced the Commission for Health In investigating allegations of serious failings Improvement, which ceased to exist on 31 in healthcare, we aim to help organisations to March 2004 improve the quality of care they provide, to build or restore public confidence in • have taken over responsibility for the healthcare services, and to seek to ensure independent healthcare sector from the that the care provided to patients is safe National Care Standards Commission, throughout the NHS. which also ceased to exist on 31 March 2004 • carry out the elements of the Audit Commission’s work relating to the efficiency, effectiveness and economy of healthcare. We have a statutory duty to assess the performance of healthcare organisations, award annual ratings of performance for the NHS and coordinate reviews of healthcare with others. We have created an entirely new approach to assessing and reporting on the performance of healthcare organisations. Our annual health check examines a much broader range of issues than in the past, enabling us to report on what really matters to those who receive and provide healthcare. 2 Investigation into Staffordshire Ambulance Service NHS Trust Summary The Healthcare Commission carried out this Background investigation at Staffordshire Ambulance Service NHS Trust as a result of serious Staffordshire Ambulance Service NHS Trust concerns first raised by West Midlands was created in 1992 and covered most of the Strategic Health Authority and further serious county of Staffordshire. Until late 2004, there concerns identified by the Healthcare was little change in the executive and non- Commission. executive team. From then on, a number of changes took place: a new chairman and a The aim of the investigation was to establish non-executive director were appointed to the whether the ways of working at the trust were trust’s board and, in March 2006, the chief adequate in ensuring the safety of users of the executive, who had been in post since the trust service and staff, and in providing a good was created, left the trust. The medical quality of service. director, who was also the deputy chief We looked at the trust’s arrangements for executive and who had been working in the clinical governance and its management of trust since 1999, left at the end of March 2006. medicines. We also examined its Following the departure of the previous chief management of its community first executive, an acting chief executive was responder schemes. (Community first appointed, along with an acting medical responders are volunteers who respond to adviser who left the trust at the end of July certain medical emergencies on behalf of an 2006. The previous medical director returned ambulance trust and give immediate to the trust on 25 July 2006 and on 1 August assistance and treatment until the arrival of 2006 he was appointed acting medical adviser. an ambulance paramedic or technician.) In addition, we explored how well the trust A joint director of clinical performance (with worked with other local NHS organisations. West Midlands Ambulance Service NHS Trust) Finally, we looked at the management and was appointed in November 2006. In March leadership of the trust, together with 2007, a chief operating officer was appointed strategic arrangements for ensuring the and replaced the acting chief executive. safety of users of the service and staff. On 1 October 2007, the trust merged with West We carried out the investigation between Midlands Ambulance Service NHS Trust. January 2007 and August 2007. Staff from the In the five years preceding the merger, Healthcare Commission worked with a team of Staffordshire Ambulance Service NHS Trust expert advisers. We met with patients, their consistently achieved and exceeded the relatives and members of the public who had Department of Health’s standards for national used the emergency and GP out-of-hours response times. It had always tried to be services, and we carried out visits to the trust innovative, both in the type of services it – both scheduled and unannounced. We used delivered and the way it delivered them. the information from these alongside evidence from interviews and analysis of documents, including policies, reports, minutes of Summary of events meetings and observations. The concerns, first raised in August 2006, related to the trust’s management of Investigation into Staffordshire Ambulance Service NHS Trust 3 medicines, including the use of controlled We also became aware that the trust’s CFRs drugs and the range of medicines and drugs were driving using blue lights and sirens. They that it allowed its community first responders had been told by the trust that they could (CFRs) to administer, as well as its systems exceed the speed limit by a maximum of 20 for introducing new equipment. The fitness to miles per hour and drive through red lights. practise of the acting medical adviser was They were allowed to do this without having also called into question, resulting in him completed a course of advanced driving being referred to the General Medical Council. instruction. To date, the concerns raised have been Our findings are set out in the full body of this considered by two GMC panels, both of which report and are summarised below. decided to take no action on his registration. West Midlands Strategic Health Authority carried out a review of the trust’s Management of medicines management of medicines. This was The management of medicines is a complex completed in November 2006 and found that area and expertise is required to ensure that the trust allowed its paramedics to possess medicines legislation and regulations are and administer drugs, for example midazolam interpreted and applied correctly. by the buccal (cheek) route, that they were not authorised to hold. Authorisation can only be The nature of the work of ambulance trusts granted if a body such as the Joint Royal means that they are often faced with unique Colleges Ambulance Liaison Committee (a problems. However, they are still required to national forum that provides advice and ensure they comply with medicines legislation. guidance on all clinical aspects relating to The trust did not have robust arrangements in care provided by ambulance staff) makes an place for the management of medicines and application to the Home Office for a group controlled drugs, and did not have the authorisation for paramedics to administer necessary resources or expertise available to midazolam. ensure their practices complied with the relevant legislation and regulations. The review also found that protocols were not always dated, few had review dates and there It took the practice of paramedics was no evidence that they had been reviewed. administering morphine seriously, but it did The protocols did not specify to whom they not consider all the potential implications and were applicable, that is whether they applied risks. There was too much focus on the specifically to paramedics, ambulance potential risk of abuse of morphine by staff, technicians, CFRs or all of them. rather than looking at all the risks of paramedics administering morphine. At the same time, the Independent Police Complaints Commission (IPCC) was The trust’s patient group directions (PGDs) – investigating an incident involving the trust written instructions for the administration of and Staffordshire Police Service, where a man named medicines to groups of patients who had died. The IPCC published a report of its may not be individually identified – were not investigation in December 2007.
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