Alex Ganski

I am Joseph TURNER, Area Coroner, for the coroner area of West Sussex, Brighton and Hove.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken,  setting out the timetable for action. Otherwise, you must explain why no action  is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These  representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be  checked for sensitive information prior to publication, as the information is  already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary .

SUMMARY OF CORONER’S CONCERN The principal concern on which I now seek comment from NHS England is as to the apparent absence of any national guidance/advice to frontline emergency crews who may be called to patients with complex and overlapping clinical, behavioural and addiction issues, but who may be unaware of the full extent of these and/or of partner agencies’ involvement.  Whilst I understand the need for ambulance services to triage patients according to their immediate presentation, this is currently a missed opportunity to update and refer them to partner agencies.