The Dame Marianne Griffiths review of North East Ambulance Service's (NEAS) alleged "covering up" of documents from coroners has finalised the terms which will shape its investigation.
Dame Marianne was appointed to lead the "independent review" of the NHS trust's coronial processes following revelations from whistleblowers who claimed key documents relating to tragic cases where patients died were not shared with coroners in a timely fashion or in some cases even altered.
NEAS has admitted "historical failings" and accepted that it let families down - but it maintains these issues have been resolved. The cases in question include those of Quinn Evie Milburn Beadle and Peter Coates. Quinn Evie died in 2018. Earlier this year, NEAS chief executive Helen Ray said the organisation would "fully engage" with the review.
Now, Dame Marianne has confirmed, in documents published by NHS England on its website, that she will be looking into nine key areas with a view to publishing findings in the first quarter of 2023. These areas include:
- "Fully understanding" the concerns raised and the impact on the families involved, along with other stakeholders.
- "Benchmarking" NEAS' current coronial processes against those of other organisations within the NHS.
- Reviewing how the trust deals with "Serious Incidents" - cases which are flagged up internally.
- Assessing whether or not NEAS' response to whistleblower's concerns "were appropriate, and in compliance with best practice, local policy and national guidance".
- It will also consider whether NEAS complies with its "duty of candour" - and specifically if it did so in the cases identified
Beyond this, the Terms of Reference highlight that Dame Marianne will seek to establish whether HR arrangements and "the use of settlement agreements and associated confidentiality clauses" has been appropriate. Though NEAS has denied it uses non-disclosure agreements, whistleblower Paul Calvert was offered a settlement which would have limited his ability to disclose information "related to the business or affairs" of NEAS.
Dame Marianne's review will also - the terms state - "identify issues in relation to culture, capacity or resources" that had impacted on either NEAS' initial response to staff members raising concerns or the current safety of patients. Considering the quality of and response to a total of seven reports NEAS itself commissioned is also part of Dame Marianne's remit, as is considering the arrangements in place for staff to "speak up".
This comes after Paul Calvert was told on December 19 that his employment will be terminated in four weeks. He said this is "as a result" of having made public interest disclosures as a whistleblower. Previously he and the Beadle family had expressed scepticism as to the independence of Dame Marianne's review - suggesting that it could be "theatre".
Speaking to ChronicleLive on Thursday evening, he said having considered the published terms, his position remained the same.
Earlier this year, when Paul first spoke publicly, NEAS said it had learned from all of the cases raised - and that is was "wrong" to say lessons had not been learned and changes made.
The circumstances around Quinn Evie's death - and that of Mr Coates - were examined by external firm AuditOne after Paul and others inside NEAS raised concerns about how candid the trust was being about its mistakes.
Investigators found that the first paramedic to attend Quinn Evie did not attempt "full advanced life support" before declaring her death. At the time, paramedics and police who were on the scene raised concerns about this, an internal investigation took place, but the coroner presiding over Quinn Evie's inquest was not told this.
AuditOne examined Quinn Evie's case and those of several others including Mr Coates - who died following delays getting ambulances to him. In his case, one ambulance was unable to attend due to issues opening electronic gates, while a second had stopped to refuel. Mr Coates, who was bedbound and reliant on oxygen, had called for an ambulance as a power cut had seen his oxygen machine fail.
He was dead by the time an ambulance arrived - 34 minutes after the first one had been dispatched.
This summer, following media attention and Paul's decision to speak out publicly, the Department of Health and Social Care and NHS England announced what they called an "independent review" into NEAS' conduct.
Though initially discussed as likely to conclude in late 2022, NHS England has confirmed it now expects Dame Marianne to produce her report in the early months of 2023. In a statement, NHS England said: "Chaired by Dame Marianne Griffiths, the review will consider the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues about the quality of information supplied to coroners.
"The Review will be published upon completion which is expected to be in the first quarter of 2023."
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