Are Prehospital Deaths From Trauma and Accidental Injury Preventable?

ARE PREHOSPITAL DEATHS FROM TRAUMA AND ACCIDENTAL INJURY PREVENTABLE? A SUMMARY REPORT Research, Evaluation and Impact #DontStopat999 Refusing to ignorRefusing to ignore people in crisise people in crisis

ARE PREHOSPITAL DEATHS FROM TRAUMA AND ACCIDENTAL INJURY PREVENTABLE? A SUMMARY REPORT Alison McNulty Research, Evaluation and Impact, British Red Cross

Copyright © 2016 Any part of this publication may be cited, translated into other languages or adapted to meet the local needs without prior permission of the British Red Cross, provided that the source is clearly stated. Photos: Front cover, pages 2, 6, 12, 28, 32: Lloyd Sturdy (BRC); pages 5, 10, 16, 22, 26, 35: Jonathan Banks; pages 14, 21, 36: Alex Rumford (BRC); page 18: 1000 Words/Shutterstock.com. Editing and layout: Green Ink (greenink.co.uk) ISBN 978-0-900228-28-5

Acknowledgements vi Foreword 1 Executive summary 3 1 Background 7 First aid education at the British Red Cross 7 Are prehospital deaths from accidental injury preventable? 9 External context 9 2 Design 13 3 Study one 15 contents Research objectives and methodology 15 4 Study two 19 Research objectives and methodology 19 5 Key findings 23 Literature review 23 Study one 24 Study two 26 6 Conclusions 29 Literature review 29 The nature and cause of death 30 Preventability of death 30 7 Recommendations 33 Recognition 33 Recommendations for the first aid training community, including the Red Cross 34 Recommendations for the Red Cross 34 Recommendations for decision-makers and policymakers 34 References 37

vi Are prehospital deaths from trauma and accidental injury preventable? A summary report Acknowledgements The British Red Cross is very grateful to Dr Govind Oliver, Dr Darren Walter and Professor Anthony Redmond, of the Humanitarian and Conflict Response Institute at the University of Manchester, for their work. The author is very grateful to Corinne Evans, Joe Mulligan and Emily Oliver at the Red Cross for their enthusiasm and support throughout this project, and for the help given by Emily May, also at the Red Cross, in the preparing the policy-related content within this report. The British Red Cross is also incredibly grateful for the support offered to the project by Her Majesty’s Senior Coroners Mr N. Rheinberg (Cheshire) and Mr N. Meadows (Manchester City).

Are prehospital deaths from trauma and accidental injury preventable? A summary report 1 Foreword n 1994 Dr Hussain and Professor Anthony Redmond completed a study which looked at the worryingly high number of people that were dying Ifrom accidental and traumatic injuries before they reached a hospital. They wanted to know if there were circumstances under which these deaths might have been prevented. At the British Red Cross, we have long believed that knowing just a few basic first aid skills can give someone the power to save a life. So, 22 years later, we have asked the question again. Working with Professor Redmond, we have learnt that tragically, the situation in 2016 is much the same. When a person is injured, many well-meaning people will rush to call 999 but few go on to provide first aid while they wait for help to arrive. We believe that most people lack the skills and confidence to do more. We know that people generally want to help but the fact that they are not equipped to step forward can lead to unnecessary deaths. There are two simple but life-saving first aid skills which we’d like everyone to learn: open a person’s airway by placing them on their side with their head tilted back, and put pressure on bleeding wounds.

2 Are prehospital deaths from trauma and accidental injury preventable? A summary report More people knowing basic first aid and being Crucially, we are also working with the government ready to use it will save lives, so we are working to call for first aid to be taught in schools, for it to hard to open people up to new ways of learning be part of the driving test, and for it to be integral throughout their lifetime. We have two smartphone to public health strategies. apps available, one covering a range of easy-to- learn first aid and one focusing on the specifics of If we can encourage people to learn enough to keeping babies and children safe. We also have a step forward and do whatever they can to help, range of courses available to help people learn as many more lives could be saved. little or as much first aid, as and when they want. Michael Adamson Chief Executive, British Red Cross

Are prehospital deaths from trauma and accidental injury preventable? A summary report 3 Executive summary he British Red Cross has a humanitarian vision: a world where everyone gets the help they need in T a crisis. As a strategic objective: ‘For those with an increased risk of experiencing a crisis, and to develop individual and community resilience, our education offer will ensure all those reached are more confident and willing to act.’ In 1994, Hussain and Redmond conducted a study of the prehospital deaths in North Staffordshire between 1987 and 1990. They revealed that up to 39 per cent of these prehospital deaths from accidental injury might have been preventable with the provision of basic first aid. As a first aid provider, we were keen to re- examine whether the number of deaths that may have been preventable with the provision of basic first aid has altered since the original study. In line with our strategic objective, we were also keen to address whether the nature and cause of injury has changed.

4 Are prehospital deaths from trauma and accidental injury preventable? A summary report Therefore, we commissioned research, under 57 per cent of cases. This is despite the injured the supervision of the original author (Professor potentially being alive at this stage. This presents Anthony Redmond), to repeat the 1994 study on a an opportunity to help, but is often a missed contemporary sample of coroners’ records. The first opportunity. study used the same historic methods of analysis. The second study refined the analysis to account for Both studies also showed that the mechanism of a more recent method of calculating the probability injury has changed, in line with trends observed of survival. Both studies analysed case records. in other studies. The number of deaths from falls increased, whereas the number of road deaths The first objective of this research was to examine decreased, but remains significant. whether there had been a change in the nature, cause and preventability of death since the original The research makes several recommendations. 1994 research. The second was to identify which, if any, interventions might reduce the number of Recommendations for the first aid training preventable deaths, with a view to informing first aid community, which includes the Red Cross: education. > Encourage action to be taken by bystanders, The studies showed that the percentage of beyond calling for the emergency services. potentially preventable or preventable deaths remains high and unchanged since 1994, and > Increase understanding that doing something is while calls for assistance were made in up to simple but life-saving: 93 per cent of cases, first aid intervention of any – maintain an open airway to keep the person kind was not as frequent. breathing by turning the person on their side and tilting their head back; A bystander or passer-by was on scene during, – put pressure on a bleed to stop the flow of immediately after or in the minutes after the point blood. of injury in up to 52 per cent of cases. However, when those found dead are excluded, a first aid > Further explore the motivation to proceed with intervention was attempted in between 43 and first aid interventions or not.

Are prehospital deaths from trauma and accidental injury preventable? A summary report 5 > Continue to test out different ways of teaching > Government education departments, schools, first aid education. teachers, young people and others should champion first aid learning, integrating it > Continue to use our knowledge and expertise into existing subjects and whole-school to identify areas with a high risk of first aid approaches. emergency. > The Welsh Government should integrate first > Consider examining the role of the call handler aid learning into planned changes to the Welsh in supporting the bystander to perform first aid. curriculum. Recommendations for the Red Cross: > The Department for Transport should make attendance at a practical first aid course > Seek to lead, along with academic colleagues, mandatory to acquire a driving licence in the the prehospital research community to UK. reach a consensus on what is considered ‘preventable’. > The Department for Transport should include bystander first aid as a key intervention in its > Consider exploring our role in responding to Road Safety Statement (2015). falls. > The departments for health and relevant Recommendations for decision-makers and national and local public bodies across the UK policymakers: should work with the Red Cross to ensure that all have the opportunity to learn first aid. > First aid should be mandatory in school curricula in England, Northern Ireland, Scotland and Wales.

6 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 7 1 Background First aid education at the British Red Cross The British Red Cross helps millions of people in the UK and around the world prepare for, respond to and recover from emergencies. As a member of the Red Cross and Crescent Movement, which is the world’s largest provider of first aid education and training, we provide learning in first aid, disasters and emergencies, and humanitarian values. We offer a variety of first aid training and resources, including high-quality face-to-face education, free online resources for young people and teachers at primary- and secondary-school level, as well as putting life-saving tools into people’s pockets through our free first aid phone apps. Overall we aim to develop effective education to reduce the harmful impacts of crises, including the skills needed to reduce harm and save lives. We aim to change behaviours and attitudes so that more people will take humanitarian action by stepping forward to help.

8 Are prehospital deaths from trauma and accidental injury preventable? A summary report The Red Cross has a humanitarian vision: a world of that education, was articulated in scientific where everyone gets the help they need in a crisis. literature (Søreide et al. 2013). This highlighted the importance of the bystander being adequately As a strategic objective: ‘For those with an equipped to step forward and be willing to help, increased risk of experiencing a crisis, and to through skills and confidence, to step forward and develop individual and community resilience, our help. The realisation of the critical role of the first education offer will ensure all those reached are person on the scene also drew attention to the more confident and willing to act.’ lack of data and insight into what makes good first aid education – that is, education which empowers To help achieve this strategic objective, the Red the learner to act effectively and gives them the Cross strives for advancements in education confidence to do so. through a strengthened evidence base, by developing its first aid offer and underpinned A 2016 survey of 600 members of the general pedagogy, alongside influencing change through public (British Red Cross, unpublished) asked its advocacy priorities. These developments not a series of questions related to their confidence only reflect the wider external context of first aid and willingness to act in a number of first aid education but have also influenced this context. emergencies: The late 1970s saw a burgeoning interest in > confidence to act when someone was prehospital care – specifically, managing the unconscious but breathing, unconscious and patient in the first stage of the chain of survival, not breathing, or bleeding severely where actions and events in each stage of their journey contribute to their chance of survival > willingness to act when someone they knew (Hsieh 2016). was unconscious but breathing, unconscious and not breathing, or bleeding severely These events include: > willingness to act when someone they did > early access to the emergency cardiac care not know was unconscious but breathing, system by recognising sudden cardiac arrest unconscious and not breathing, or bleeding quickly and calling 911 severely. > early cardiopulmonary resuscitation (CPR) by The survey revealed that confidence was a greater those nearest to the sudden cardiac arrest i.e. issue than willingness in all three emergency bystanders scenarios. > early defibrillation of ventricular arrhythmias With an ambition to reach the general population – but with the public displaying little confidence – > early advanced-level care by trained and a need to position first aid as a public health professionals (Hsieh 2016). issue, a new strategy for first aid was required. What is Everyday First Aid and why is it Based on the experiential/facilitation approach important? which has gained currency in the last 10 years, the Everyday First Aid approach was developed in This interest in prehospital care led to the use line with current good educational practice which of the relevant learning from clinical research allows for flexibility in delivery and firmly roots its to create a first aid training offer and saw the teaching methodology in active learning. This development of the inaugural first aid manual. approach encompasses: Set against a backdrop of clinically focused > flexibility in its approach to delivery, allowing a research, the offer of first aid centred on decision- greater variety of people to learn first aid making pathways – arguably containing complex information and assessment criteria – which we > appreciation of the ways in which adults and now understand does not give the general public young people learn and the influences on their confidence to act in an emergency. learning It was not until 2010 that a new ‘formula for > a variety of teaching resources, including a survival’, which acknowledged the importance of mobile app both effective education and local implementation

Are prehospital deaths from trauma and accidental injury preventable? A summary report 9 > placement of the learner at the centre, and has altered since the original study. In line with our making the experience as relevant and strategic objective, we are also keen to address empowering for them as possible. whether the nature and cause of injury have changed. The Red Cross monitors the effectiveness of education by measuring learner confidence before and after sessions. This allows us to scrutinise External context our own delivery as education providers and to implement continuous improvement. Research is Educational setting also undertaken to examine the effectiveness of different pedagogies with different audiences to Given the lack of action by bystanders found in inform our education strategy. Hussain and Redmond’s original study (1994), the authors recommended that “training in basic first Understanding where, why and how death aid should be compulsory in schools” (p.1079). and injury occur, and the likelihood that first aid Despite widespread public support for such a interventions could have made a difference, is move and campaigns run by the Red Cross and 1 central to our efforts. others to make first aid mandatory in all state- funded secondary schools in England, this goal of Are prehospital deaths from mandatory first aid has not been realised. accidental injury preventable? In England, first aid does feature in the recommended Personal, Social, Health and In 1988, a Royal College of Surgeons (RCS) Economic (PSHE) education curriculum, but this retrospective study of 1,000 trauma deaths is not a statutory subject and is not widely taught reported on the management of patients with to a high standard, according to the House of major injuries (Saleh 1989). The RCS report Commons Education Committee (2015). The concluded that up to one-third of hospital trauma Committee and other Committee Chairs recently deaths could have been prevented, if the response recommended making PSHE compulsory from the emergency health system had been (Commons Select Committee 2016), but the UK optimal. In others words, something could or Government decided not to do so (Morgan 2016). should have been done to alter the final outcome for the patient. However, the report did not include PSHE is not the only route through which to deaths that occurred outside hospital. This teach first aid. It could be taught in a variety of exclusion implies a perceived inevitability of death other existing subjects or cross-cutting curricula, occurring prior to receiving professional help. including Physical Education and as an after- school activity. Furthermore, publicly funded Challenging this assumption, Hussain and academies present an opportunity to increase Redmond (1994) conducted a study of the the teaching of first aid since, as they continue prehospital deaths from accidental injury in North to increase in number and now form almost half Staffordshire between 1987 and 1990. They of all secondary schools (Parliament UK 2015b), revealed that up to 39 per cent of these deaths they do not need to follow the curriculum, might have been preventable with the provision of although they must teach “a broad and balanced basic first aid. curriculum” (Department for Education 2015, p.38). Academies may, therefore, be well placed to Dean et al. (2014) report that 37.1 per cent of the incorporate whole-school approaches and could people attended to by the emergency services embrace first aid as part of a broader theme, such who die do so before reaching hospital, with the as health and well-being, across various aspects remainder dying in hospital. The time period before of school life. hospitalisation is, therefore, critical. It is during this time, prior to professional intervention, when the Education is a devolved matter; therefore, different public is in a position to intervene with basic first approaches are adopted across the UK. Wales aid, and this intervention may well be life-saving. has a similar curriculum to England’s, with first Oliver and Walter (2016) refer to the prehospital aid optional within the statutory Personal and period as the ‘therapeutic vacuum’. Social Education (PSE) (Department for Children, As a first aid provider, we are keen to re-examine 1 These include ‘Pupil Citizen Lifesaver’ (2013) and ‘Every Child a whether the number of deaths that may have been Lifesaver’ (2015), the latter a collaboration with St John Ambulance and the British Heart Foundation in support of Teresa Pearce MP’s private preventable with the provision of basic first aid members’ bill (Parliament UK 2015a).

10 Are prehospital deaths from trauma and accidental injury preventable? A summary report Education, Lifelong Learning and Skills 2008). The Department for Transport (DfT) British Road However, a new curriculum is currently being Safety Statement (2015) notes that around 1,700 developed in Wales. Pioneering schools have people die from road deaths per year in the UK been tasked with developing the new curriculum, (based on deaths between 2012 and 2014), which will abolish key stages and move closer and that from 2005 to 2014, the number of road to the Scottish model, where there is less formal deaths fell by 45 per cent, with 2013 seeing the assessment. Key themes in the proposed fewest deaths on Britain’s roads since records curriculum include Health and Well-being, within began in 1927. One of the reasons for this is noted which first aid could fit (Welsh Government 2016). as “better trauma care” (ibid. p.9). Health and Well-being is also present in Scotland’s ‘Curriculum for Excellence’ for all ages (Education The reduction in the number of road deaths is Scotland 2010). Personal Development and a huge success, but variations in risk do occur. Mutual Understanding (PDMU) at primary level Younger drivers are said to be “four times more and Learning for Life and Work at secondary likely to be killed or seriously injured compared level are relevant subjects for first aid to be taught with car drivers aged 25 or over” (ibid. p.14). in the Northern Irish curriculum (Council for the However, older drivers and passengers are “more Curriculum, Examinations and Assessment 2007). likely to die or sustain a severe injury than a younger adult in an accident of the same impact” In England, only 24 per cent of secondary schools (ibid. p.14). teach first aid – even though surveys have revealed that the overwhelming majority of teachers, It is clear from the Statement that road safety parents and young people across the UK believe management remains a priority. However, there they should learn first aid in school (British Heart are also a number of opportunities for first aid Foundation, British Red Cross, St John Ambulance education that do not currently feature in the 2015): Statement, which speaks of the need for a wider approach to saving lives than road safety alone > 97 per cent of teachers think it is vital for young – specifically, the opportunity to educate drivers people to learn essential first aid skills in school. and the ability of statutory and non-statutory organisations to respond in the event of an incident. > 95 per cent of parents agree that first aid should be taught at secondary school. Among the key priorities outlined in the Statement are: > 97 per cent of children aged 11 to 16 agree they should be taught first aid, saying it should either > “Ensuring that the driver testing and training definitely or probably be taught at secondary regime prepares new drivers for a wide range school. of real-life driving conditions and situations; In Europe, first aid is mandatory in Denmark, > Continuing our THINK! campaign to provide France, Germany, Italy and Norway for secondary- road user education and influence behaviour in school students (IFRC 2015). In Spain and France a targeted and engaging way; first aid is also compulsory for primary-school children. As a result, in Norway, for example, > Working in partnership with public- and private- around 95 per cent of the population are educated sector bodies and civil society organisations to in first aid (ibid.). save lives” (ibid. p.6-7). Road deaths “…every road death and serious injury is a tragedy that leaves a life ruined and a family shattered.” (Department for Transport British Road Safety Statement 2015, p.10) Hussain and Redmond (1994) reported that the main cause of death, in their study, was injuries sustained on the road. However, in the 22 years since their report, changes have been observed in the mechanism of injury, with the number of road deaths declining in the UK.

Are prehospital deaths from trauma and accidental injury preventable? A summary report 11 In addition, the five pillars of the United Nation’s 573,000 to 1.4 million by 2032 (ibid.). Support is, 2010 Global Plan for the Decade of Action for therefore, vital. Road Safety 2011–2020 (WHO, 2010) include the following: “Post-Crash Response: Working with The changes in demographics mean demand is the emergency services and NHS [national health growing for health and social care (Parliament services] to ensure that collisions are effectively UK 2013). While it has long been recognised that responded to and investigated.” prevention is better than cure, the UK’s health and social care system has largely focused on However, apart from safety awareness through edu- reacting to crises rather than preventing them cation there is no suggestion made that the public, (HM Government 2012). including those involved in or witness to a road traffic collision, have a role to play in saving lives. All parts of the UK have taken steps to shift the balance of care towards prevention. In 2014 the This is surprising, given that many other European ambition to shift towards a truly preventative nations require new drivers to learn first aid through system in England was enshrined in law. Section 2 a practical test in order to qualify for a licence, of the Care Act places a new duty on local thereby increasing the likelihood that they will be able authorities to ensure the provision of services that to respond with basic but life-saving skills during prevent, reduce or delay the need for care and an emergency situation on the road, or indeed in support (HM Government 2014). The law is clear: other situations (IFRC 2015). This is the case in while the ambition is always to prevent crises, we the Czech Republic, Germany, Hungary, Norway cannot prevent every crisis. Prevention is, therefore, and Switzerland, among other countries (House of also about ensuring the resources are in place to Commons Hansard 2016). reduce the negative impact of crises. Since Hussain and Redmond’s report in 1994, the At the same time in Scotland, legislation was passed Driving Theory Test has contained a number of which integrated health and social care (Scottish first aid questions. However, despite Hussain and Government 2014a). The Public Bodies (Joint Redmond’s recommendation (p.1079), first aid has Working) Act (Scotland) 2014 set out the duties not become a compulsory practical element of the and responsibilities for integration and outlined it as driving test. a key driver in delivering transformational change with person-centred care and prevention at its core In March 2016 Will Quince MP introduced a private (Scottish Government 2014b). members’ bill under the Ten-Minute Rule in the UK Parliament, which proposed attending a four-hour In Wales, The Social Services and Well-being practical first aid course with an approved provider (Wales) Act 2014 provides the legal framework as a minimum requirement for attaining a driving for improving the well-being of people who need licence (House of Commons Hansard 2016). While care and support, and carers who need support, the bill did not have sufficient time to progress during and for transforming social services in Wales the parliamentary calendar, it has helpfully raised the (Welsh Government 2016). The Act is designed profile of the issue and given impetus for change. to encourage a renewed focus on prevention and early intervention (Welsh Government 2014). Health and social care – falls Transforming Your Care in Northern Ireland has The UK’s population is ageing fast. More than been the key policy driver in shifting care towards 1 in 12 of the population is projected to be aged prevention (Northern Ireland Executive 2016). It 80 or over by mid-2039 (ONS 2015), and a large sets out a vision for improving care for people in elderly population means an increase in the number Northern Ireland by supporting people to live as of accidental injuries from slips, trips and falls independently and healthily as possible, for as long (Oliver 2013). as possible (Health and Social Care Board 2011). By 2032, 11.3 million people are expected to be Given the changes in the external context since living on their own – more than 40 per cent of 1994 – changes to both trauma care and the all households (The King’s Fund 2012). This has nature of injury – the Red Cross commissioned the implications for responding to accidental injury, original author (Professor Anthony Redmond) and such as falls in the home, given there may not be colleagues (Dr Govind Oliver and Dr Darren Walter) a bystander present to help. Indeed, the number at the Humanitarian and Conflict Response Institute of people over 85 living on their own and likely (HCRI) at the University of Manchester, UK, to con- to be vulnerable to falls is expected to grow from duct a revised version of the original 1994 study.

12 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 13 2 Design hile commissioning the study, the researchers reported that a different approach to the analysis W of probability of survival was required. They proposed a refined methodology to account for updates to both the Abbreviated Injury Scale (AIS) and the calculation of the probability of survival. As these adaptations meant a direct historical comparison would not be possible, we decided to commission two related studies. Study one used the same methodology as the original 1994 study and applied this to more recent coroners’ records. Study two used the updated AIS and calculation for the probability of survival. Both analysed case records. Both studies are authored by Oliver, Walter and Redmond and, at the time of publishing this summary report, have been submitted to a specialist journal for publication.

14 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 15 3 Study one Research objectives and methodology Research objectives The first objective of this research was to examine whether there had been a change in the nature, cause and preventability of death since the original 1994 study. The second was to identify which, if any, interventions might reduce the number of preventable deaths, with a view to informing first aid education. Methodology This study replicated the methodology described in Hussain and Redmond (1994). 2 Several of Her Majesty’s (HM) coroners were contacted with details of the study and a request for their support. After securing 2 All sudden, unexplained and violent or unnatural deaths that occur in the UK are referred to a coroner for the jurisdiction within which the death occurs for investigation.

16 Are prehospital deaths from trauma and accidental injury preventable? A summary report support from HM Senior Coroner for Cheshire injury to discovery and the time from discovery to and receiving ethical approval from the University the call for assistance. of Manchester Research Ethics Committee, the researchers retrospectively reviewed inquest The inclusion criteria for the study were that records. deaths were from traumatic or accidental injury, within the three-year time frame and occurred The inquest records reviewed covered all deaths prior to hospitalisation. Figure 1 details both from injury referred to the coroner between inclusion and exclusion criteria. 1 January 2011 and 31 December 2013, and included the coroner’s report, police and Analysis ambulance statements, witness reports, the pathologist’s report and the post-mortem record. For each death, the following analysis was The three-year period was chosen to allow for the conducted to generate the probability of survival: completion of inquests. > In accordance with the AIS-1990, injuries were Data collected included: injuries sustained, ranked on a scale of one to six, with one being neurological injury, airway obstruction, co- minor, five severe and six a non-survivable morbidities and the presence of alcohol/other injury (Brohi 2007a). The AIS-1990 was used drugs. Details as to whether a bystander was to ensure comparison to the 1994 study. present, how the injured was discovered and 3 whether any first aid intervention was made were > From the AIS-1990, the Injury Severity Score also noted, alongside an estimate of time from (ISS) was calculated, which allows for an 3 The call for assistance was not classified as a first aid intervention.

Are prehospital deaths from trauma and accidental injury preventable? A summary report 17 FIGURE 1. FLOW DIAGRAM DETAILING INCLUSION AND EXCLUSION OF CASES FOR STUDY ONE Deaths referred to the coroner due to injury: n = 564 Deaths excluded: n = 401 Hospital death: n = 243 Death occurred overseas: n = 19 Prehospital deaths: n = 163 Death due to hanging: n = 139 Further deaths excluded: n = 29 End-of-life care: n = 12 Deaths meeting inclusion Medical or natural cause of death: n = 16 criteria: n = 134 Records not located: n = 1 overall score as a result of multiple injuries. together to produce the ISS score, which Each injury was allocated to one of six ranges from 1 to 75 (TARN 2016). body regions (head, face, chest, abdomen, extremities (including pelvis), external) (Brohi > Probability-of-survival estimations were 2007b). The three most severely injured body calculated using Bull’s probits (Bull 1975).4 regions had their score squared and added 4 In 1975 Bull used the ISS to re-analyse the data on 1,333 victims of road traffic accidents treated as inpatients at Birmingham Accident Hospital in 1961. He used probit analysis to linearise the mortality data in separate age groups and showed a good correlation between the ISS and the probability of survival when this North American method was applied to a British population. ‘Bull’s probits’ have been used by several other authors to identify preventable deaths from injury.

18 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 19 4 Study two Research objectives and methodology Research objectives The first objective of this research was to examine the nature, cause and probability of survival in a cohort of prehospital deaths. A second objective was to identify which, if any, interventions might reduce the number of preventable deaths, with a view to informing first aid education. Methodology Several HM coroners5 were contacted with details of the study and a request for their support. After securing support from HM Senior Coroner for Cheshire and HM Senior Coroner for Manchester (City) and receiving ethical approval from the University of Manchester 5 All sudden, unexplained and violent or unnatural deaths that occur in the UK are referred to a coroner for the jurisdiction within which the death occurs for investigation.

20 Are prehospital deaths from trauma and accidental injury preventable? A summary report Research Ethics Committee, the researchers Analysis retrospectively reviewed inquest records. For each death, the following analysis was The inquest records reviewed covered all deaths conducted to generate the probability of survival: from injury referred to the coroner between 1 January 2011 and 31 December 2013, > First, in accordance with the AIS-2005 (update and included the coroner’s report, police and 2008), injuries were ranked on a scale of one ambulance statements, witness reports, the to six, with one being minor, five severe and pathologist’s report and the post-mortem record. six a non-survivable injury (Brohi 2007a). The The three-year period was chosen to allow for the AIS-1990 was used to ensure comparison to completion of inquests. the 1994 study. Data collected included: injuries sustained, > From the AIS-2005 (update 2008), the ISS was neurological injury, airway obstruction, co- calculated, which allows for an overall score morbidities and the presence of alcohol/other as a result of multiple injuries. Each injury was drugs. Details as to whether a bystander was allocated to one of six body regions (head, present, how the injured was discovered and face, chest, abdomen, extremities (including 6 whether any first aid intervention was made were pelvis), external) (Brohi 2007b). The three most also noted alongside an estimate of time from severely injured body regions had their score injury to discovery and the time from discovery to squared and added together to produce the the call for assistance. ISS score, which ranges from 1 to 75 (TARN 2016). The inclusion criteria for the study were that deaths were from traumatic or accidental injury, > Probability-of-survival estimations were within the three-year time frame and occurred prior calculated using TARN’s Ps14 calculator, to hospitalisation. Figure 2 details inclusion and although this calculation has not been validated exclusion criteria for Cheshire, and Figure 3 details for a prehospital model. the same for Manchester (City). FIGURE 2. FLOW DIAGRAM DETAILING INCLUSION AND EXCLUSION OF CASES (CHESHIRE) Deaths referred to the coroner due to injury: n = 564 Deaths excluded: n = 401 Hospital death: n = 243 Death occurred overseas: n = 19 Prehospital deaths: n = 163 Death due to hanging: n = 139 Further deaths excluded: n = 29 End-of-life care: n = 12 Deaths meeting inclusion Medical or natural cause of death: n = 16 criteria: n = 134 Records not located: n = 1 6 The call for assistance was not classified as a first aid intervention.

Are prehospital deaths from trauma and accidental injury preventable? A summary report 21 FIGURE 3. FLOW DIAGRAM DETAILING INCLUSION AND EXCLUSION OF CASES (MANCHESTER (CITY) Deaths referred to the Manchester (City) coroner screened for inclusion: n = 580 Deaths excluded: n = 376 Hospital death: n = 300 Death occurred overseas: n = 10 Further analysis of deaths: n = 204 Death due to hanging/asphyxia: n = 66 Further deaths excluded: n = 160 Death not due to injury: medical/natural or open cause of death: n = 112 Deaths meeting inclusion End-of-life care: n = 3 criteria: n = 44 Notes missing or not located: n = 45

22 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 23 5 Key findings Literature review At the start of the research, a systematic literature review was conducted to examine the heterogeneity in terminology and methodology across studies into preventable prehospital trauma deaths (see Oliver and Walter 2016 for the full report). This review revealed inconsistencies in both the methodologies employed and the terminology used to define ‘preventable’ deaths. The studies were also inconsistent in their inclusion of those dead at the scene or dead on arrival in their analysis. These inconsistencies affirmed for the authors that no key research could be used as a comparator to the revised 1994 study (study one). They also concluded that research into preventability in the therapeutic vacuum, which occurs prehospital (before professional intervention), will be inhibited without homogeneity in the methodologies and terminologies of prevention. There is, therefore, a need for the research community to reach consensus on prevention in the prehospital space.

24 Are prehospital deaths from trauma and accidental injury preventable? A summary report Study one collisions (RTCs)7 in the present study (27.6 per cent, n = 37) than previously (56.6 per cent, n Sample characteristics = 86), though it is clear that this cause of injury still accounts for a sizeable proportion of overall One hundred and thirty-four deaths met the deaths. The proportion of those who died after the inclusion criteria, which is slightly fewer than the RTC was similar for both studies: 45.9 per cent 1994 study (n = 152). (n = 17) car occupants vs. 43.0 per cent (n = 37) previously, and 29.7 per cent (n = 11) pedestrians While gender was broadly comparable between vs. 25.6 per cent (n = 22) previously. This is similar both studies (110 male and 42 female vs. to current statistics for road deaths in Great 106 male and 28 female in the previous study), Britain, with car deaths accounting for 44 per cent the current sample was older than in the original and pedestrian deaths for 24 per cent of road study, with a mean age of 53.6 years compared deaths (DfT 2015). to 41.9 years. However, these trends are in line with existing research, where the average age of In contrast to the decrease in the number of death from injury increased from 36.1 years in RTCs, the number of falls was observed to have 1990 to 53.8 years in 2013 (Kehoe et al. 2015). increased as a main mechanism of injury in the Furthermore, a gender difference is also observed present study (38.8 per cent, n = 52 vs. 15.1 per in the proportion of deaths from injuries, with cent, n = 23). Of these falls, 48.1 per cent (n = 25) a higher proportion of male deaths from injury were as a result of a low-energy fall (at the same (1 in 8) than female (1 in 14) (WHO 2008). level) and 51.9 per cent (n = 27) a high-energy fall (above body height). This increase in the number Time of death of falls is in line with findings from Kehoe et al. (2015) that show that the most common cause Table 1 displays the available data related to of injury has shifted from RTCs (59.1 per cent in whether the injured person was found dead, dead 1990) to low-level falls (39.1 per cent in 2013). at the scene or dead on arrival: Deaths from falls were analysed further, and it > 46.3 per cent (n = 62) of the injured were found was observed that this cohort was more likely to dead, where the injury was not witnessed, and be male (36 male vs. 16 female) and older, with death was declared immediately on discovery an average age of the deceased at 64.7 years of the body (interquartile range 46 to 82). In 88.5 per cent of cases, the fall was accidental. > 43.3 per cent (n = 58) were dead at the scene, where bystanders were present at the time of Based on the coroner’s records, being found dead injury or prior to death after a fall was more frequently observed than dead at the scene or dead on arrival – 71.2 per 10.4 per cent (n = 14) were dead on arrival, where cent, 23 per cent and 5.7 per cent, respectively. death occurred following transportation from the Of the 12 who were dead at the scene, all but one scene but prior to hospitalisation or when declared had either a bystander present or there within a within the emergency department. minute, and the three who were dead on arrival at hospital all had a bystander present immediately or Mechanism of injury within minutes. The majority of deaths in the current study were as Of those found dead, 22 of the 37 were aged a result of accidental (unintentional) injury (71.6 per 71 years or over, and none of the 22 had a cent, n = 96). There were fewer road traffic bystander or passer-by present within hours. Table 1. Status of injured person on discovery It is noteworthy that significantly more hangings were observed in the current study than in 1994. Cheshire The proportion of hangings rose from 9 per cent % (number) (n = 30) of the original study sample to 25 per cent Found dead (n = 139) in this present study (p<.05). 46 (62) Dead at the scene 43 (58) Dead on arrival 10 (14) 7 Including motor vehicle injury, motorcycle injury, bicycle injury and Note: Some figures are rounded down pedestrian; excluding other traffic (ship, aircraft, train).

Are prehospital deaths from trauma and accidental injury preventable? A summary report 25 Calculating the probability of survival (median 6 minutes), although these data were only available for 50 cases. However, this time The average ISS was 38.3. Twenty-nine deaths in frame adds to the only detail we have about the both the current and previous study had an ISS therapeutic vacuum – in 95.5 per cent of cases a of 75 (the maximum possible and considered not passer-by was with the injured person, but without survivable). An ISS greater than 15 is considered professional support. a major trauma. In the current study, 22 deaths had an ISS of less than 15, compared to 14 in the The majority of calls for assistance were made by previous study. a bystander or passer-by (85.1 per cent, n = 114), and in 11 cases (8.2 per cent) by someone The probability of survival remained high in both involved in the incident. studies. In 1994, 39.5 per cent (n = 60) of cases had a probability of survival greater than 50 per When we exclude those who were found dead, cent, compared to 43.3 per cent of people in the a first aid intervention was attempted in 43.1 per present study (n = 58). cent (n = 31) of cases. When including those found dead, in only two additional cases was an The presence of airway obstructions alone was intervention attempted. lower in the present study (19.4 per cent, n = 26) than previously (58.6 per cent, n = 89). In addition, Types of intervention which might help of these 26 deaths, 20 (76.9 per cent) also had a neurological injury, which is similar to the Although the presence of airway obstruction proportion in the previous study (79.8 per cent, alone was slightly lower in the current study than n = 71). Overall, neurological injury was noted previously, the presence of neurological injury and in 102 deaths (76.1 per cent). Similarly, in 1994, neurological injury with airway obstruction was 113 deaths were associated with neurological similar between the studies. Therefore, the original injury (74.3 per cent). recommendation from 1994 – to maintain airways as an important intervention – still stands. Bystander presence However, the current study places greater Data on the presence of a bystander, and how the emphasis on the need to provide ventilatory call for assistance was made, were not collected intervention when a head injury has occurred, in the original 1994 study. This was addressed particularly due to the subsequent physiological in the current study, as it allows for speculation response to brain injury, known as impact brain around the moments after injury and the possibility apnoea. If the airway is supported during this for first aid intervention. time, then death from prolonged apnoea may be avoided (Wilson et al. 2016). Oliver and Walter A bystander was on the scene during or (2016) note that this critical phase of a head injury immediately after the point of injury in 44.8 per takes place in the first 10 minutes, although they 8 cent of deaths (n = 60). For an additional 20 also state that this is an arbitrary time reference people (14.9 per cent), a bystander was on the (Atkinson 2000). scene between minutes and an hour later. A passer-by was on the scene before the emergency The authors of the present study note the services in 95.5 per cent of cases. importance of the role of the bystander or passer-by in supporting the airway and controlling The average time taken for the emergency bleeding. services to arrive after call-out was 8.2 minutes 8 The time from injury to discovery is a subjective assessment of the time from the point of injury to someone being on the scene, based on the available evidence.

26 Are prehospital deaths from trauma and accidental injury preventable? A summary report Study two Sample characteristics One hundred and thirty-four deaths from the Cheshire data met the inclusion criteria, and forty- four from Manchester (City). While there were significantly more accidental deaths in Cheshire than in Manchester (City) (71.6 per cent vs. 54.5 per cent, p<.05), gender (79 per cent vs 77 per cent male) and age (53.6 years vs. 48.2 years) were comparable. The average age observed in the current study reflects trends in the hospital trauma population, In contrast, fewer deaths were observed as 9 where the average age of death from injury is a result of motor vehicle injury; these deaths 53.8 years (Kehoe et al. 2015). Furthermore, a accounted for 27.6 per cent (n = 37) in Cheshire gender difference is also observed in deaths from and much fewer in Manchester (City) (15.9 per injuries, with a higher proportion of male deaths cent, n = 7). This cause of injury, however, still from injury (1 in 8) than female (1 in 14) (WHO accounts for a sizeable proportion of overall 2008), albeit from a global population. deaths. Time of death The proportion of those who died after a RTC was reversed for the two cohorts. In Cheshire, 45.9 per Table 2 displays the available data related to cent (n = 17) of those deceased following an RTC whether the injured person was: were car occupants, and 29.7 per cent (n = 11) were pedestrians, compared to 29 per cent (n = 2) > found dead, where the injury was not car occupants and 43 per cent (n = 3) pedestrians witnessed, and death was declared in Manchester (City). However, the lower numbers immediately on discovery of the body in Manchester (City) are likely to have shaped this finding. Certainly the Cheshire data are more > dead at the scene, where a bystander were aligned with current statistics for road deaths present at the time of injury or prior to death, or in Great Britain, with car deaths accounting for 44 per cent and pedestrian deaths for 24 per cent > dead on arrival, where death occurred following of road deaths (DfT 2015). transportation from the scene but prior to hospitalisation or when declared within the Overall, this pattern of injury is in line with external emergency department. research, which notes that the most common cause of death from injury has shifted from RTCs Mechanism of injury (59.1 per cent in 1990) to low-level falls (39.1 per cent in 2013) (Kehoe et al. 2015). Significantly more deaths in Cheshire were accidental (p<0.05), and fewer due to assault Calculating the probability of survival (p<0.05), than in Manchester (City). Traumatic brain injury was noted in 76 per cent of Cheshire The average ISS was similar for both cohorts cases, compared to 66 per cent of those in – 38.2 for Cheshire and 36.1 for Manchester Manchester (City). (City). However, 29 Cheshire deaths had an ISS of 75 (the maximum possible and considered not The main mechanism of injury for both Cheshire survivable), compared to 7 in Manchester (City). In and Manchester (City) deaths was falls (39 per addition, 21 Cheshire deaths and 5 Manchester cent and 45 per cent, respectively). Of these falls, (City) deaths had an ISS of less than 15, which the Manchester (City) coroner’s reports reveal a does not qualify as a major trauma. higher proportion of deaths by high-energy falls than in Cheshire (85 per cent and 52 per cent, respectively, p<0.05). 9 Including motor vehicle injury, motorcycle injury, bicycle injury and pedestrian; excluding other traffic (ship, aircraft, train).

Are prehospital deaths from trauma and accidental injury preventable? A summary report 27 Table 2. Status of injured person on discovery Cheshire Manchester (City) % (number) % (number) Found dead 46 (62) 48 (21) Dead at the scene 43 (58) 34 (15) Dead on arrival 10 (14) 18 (8) Note: Some figures are rounded down Using the WHO (2008) definition of potentially The vast majority of calls for assistance were made preventable or preventable (based on an estimated by someone directly involved in the incident, a probability of survival of 25 to 50 per cent and bystander or a passer-by (93 per cent in Cheshire greater than 50 per cent, respectively), 45 per cent and 86 per cent in Manchester (City)). of Cheshire deaths and 59 per cent of Manchester (City) deaths were potentially preventable or Excluding those found dead, a first aid intervention preventable. was attempted in 43 per cent of the remaining cases in Cheshire and 57 per cent in Manchester Bystander presence (City). Information on the presence of a bystander, and Types of intervention which might help how the call for assistance was made, allows for speculation around the moments after injury and Given the high incidence of traumatic brain injury, the possibility for first aid intervention. A bystander the current study places greater emphasis on was on the scene during or immediately after the the need to provide ventilatory intervention when point of injury in 45 per cent of deaths (n = 60) in a head injury has occurred, particularly due to Cheshire and 43 per cent (n = 19) in Manchester the subsequent physiological response to brain 10 (City). A passer-by was on the scene within injury, known as impact brain apnoea. If the airway minutes in an additional 7 per cent (n = 9) of cases is supported during this time, then death from in Cheshire and 5 per cent (n = 4) in Manchester prolonged apnoea may be avoided (Wilson et al. (City). Furthermore, a bystander or passer-by was 2016). on the scene prior to the emergency services in 96 per cent of Cheshire deaths and 86 per cent of Oliver et al. (2016) go on to note that traumatic Manchester (City) deaths. brain injury is the commonest mode of death following traumatic injury and that the critical In Cheshire, the mean average time taken for the phase of a head injury takes place in the first emergency services to arrive after call-out was 10 minutes, although they also note that this is an 11 8.4 minutes (median 6.5 minutes). In Manchester arbitrary time reference (Atkinson 2000). (City) the average time was 8.1 minutes (median 7 minutes).12 10 The time from injury to discovery is a subjective assessment of the time from the point of injury to someone being on the scene, based on the available evidence. 11 Based on data from 50 records. 12 Based on data from 36 records.

28 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 29 6 Conclusions his report summarises the findings from a literature review (Oliver and Walter 2016) plus two empirical studies T currently submitted to a specialist journal for publication by Oliver, Walter and Redmond. The overall aim of this programme of research was to examine whether there has been a change in the nature, cause and preventability of death since the original 1994 research (study one), and whether there has been a change in the preventability of death, using a more recent calculation of the probability of survival (study two). Literature review Changes to the care of injured patients have been significant, improving on the deficiencies noted across a range of reports (Sleat and Willett 2011; Yates et al. 2002). However, trauma registries – the measures used to audit and monitor performance – have yet to extend into what Oliver and Walter (2016) refer to as the ‘therapeutic vacuum’.

30 Are prehospital deaths from trauma and accidental injury preventable? A summary report The therapeutic vacuum occupies the prehospital study one found that 43.3 per cent of people had space between the emergency occurring and a probability of survival greater than 50 per cent, professional help being provided. Without the compared to 39.5 per cent in the 1994 study. development of indicators to measure activity When the more recent analysis method was used during this period, there remains a perception of to calculate the probability of survival, study two the inevitability of death in this space and a lack of found that between 45 per cent and 59 per cent of a clear definition of what is meant by prevention in deaths were potentially preventable or preventable the prehospital space (ibid.). according to WHO definitions (2008). The percentage of potentially preventable or The nature and cause of death preventable deaths remains high and unchanged since 1994 and, although calls for assistance All studies, including the 1994 original, had a were made in up to 93 per cent of cases, first aid comparable sample in relation to gender; however, intervention of any kind was infrequent. age at death from injury had increased to the same average age observed in other research (see A bystander or passer-by was on the scene Kehoe et al. 2015). during, immediately after or in the minutes after the point of injury in up to 52 per cent of cases. Both studies showed that the mechanism of injury However, when those found dead are excluded, has also changed, in line with trends observed a first aid intervention was attempted in between in other studies. The number of deaths from falls 43 and 57 per cent of cases. This is despite the increased, whereas the number of road deaths injured potentially being alive at this stage. This decreased. However, the proportion of car presents an opportunity to help, but is often a occupants and pedestrians dying from injuries missed opportunity. sustained on the road remained comparable to the 1994 study, which suggests that the vulnerability The authors of the studies had only the coroners’ of the driver in particular remains high. records from which to collect data and did not examine the role of the emergency call handlers Although outside the scope of this research, in supporting people who have dialled 999 to there was a significant increase in the number perform first aid. Therefore, no assumption can be of hangings observed compared to the 1994 made as to the content of these telephone calls; study. UK suicide rates have fluctuated over the however, an exploration of these conversations past 30 years. According to the ONS (2016a), in would be an interesting route for future research. 2010 the rate was 10.2 per 100,000 population, compared to 13.2 in 1990. However, the The interventions which the authors suggest could proportion of suicides in the UK from hanging, be beneficial during the therapeutic vacuum are strangulation and suffocation has increased. supporting the airway and controlling bleeding. Between 2002 and 2012, this proportion rose This aligns with the skills that members of the from 45 per cent to 58 per cent for men, and public wish to learn. In an online survey of 1,035 from 26 per cent to 36 per cent for women. It individuals who were interested in learning first aid was not the intention of the current studies to but had neither attended a course in the last year explore suicide or the variables that might explain nor worked in a place where they were required its incidence, such as location, personal factors to have first aid training, the top five emergencies and demography. However, there is room for they wanted to be taught the skills to respond future research to examine the apparent increase to were: heart attack, unconscious and not found in this study and what factors might have breathing, unconscious and breathing, bleeding influenced this trend. heavily, and choking (adult) (Flood and Campbell 2014). Preventability of death In practice, therefore, there is a need to turn those interested in first aid into those who attend training It is clear that little has changed in terms of the and then act in an emergency. The key issue is percentage of people whose death may have been how to motivate people to learn and act. preventable, although the mechanism of injury has changed. Our knowledge of the bystander effect helps us understand why people do or do not act in an When compared to the 1994 study findings, using emergency. This phenomenon has received much the same historic analysis for probability of survival, research attention and, as such, has resulted in

Are prehospital deaths from trauma and accidental injury preventable? A summary report 31 a range of reasons for action or inaction. Early be nearby immediately, so while it is still vitally research into this social phenomenon proposed important to ensure that the 25 per cent of people that a diffusion of responsibility was the key reason found injured and possibly alive are found by a why people do not act (Latane and Darley 1968a). person trained in first aid, a different additional However, our understanding has grown, and we strategy is also required to aid the remaining now understand action to be also affected by 75 per cent. There may well be opportunities the context in which the emergency takes place, to prevent falls or, when falls happen, a swifter including how our perception of how much alike way to raise the alarm to bring about a first aid we are to those injured (referred to as belonging to intervention at the earliest opportunity. the/our ‘in-group’) influences our decision to act (Levine et al. 2002 and 2005; Levine and Crowther Previous Red Cross research (White and 2008). While we cannot deduce the nature of McNulty 2011) has shown that first aid can make the relationship between bystanders and the communities more resilient; therefore, there may deceased in the studies reported herein, the fact well be value in exploring how best community that the bystander was on the scene immediately members can support each other – especially or within minutes suggests that there is a likelihood those who are living alone. that they may well have known the deceased. And yet these people still did not always provide basic Assistive technology has become increasingly first aid. popular to support people with health and care needs – including frailty – who live alone Looking specifically at the two main causes of (Department of Health 2013). A popular form is death – road deaths and falls – there are clearly ‘push button care’, where help can be called for missed opportunities to provide first aid. In their by pressing a button on a pendant or wrist strap. review of the available literature, Hall et al. (2013) The device is connected to a telephone landline found evidence to suggest that drivers are more and a power supply via a simple unit installed willing to stop at the scene of an accident if they in the home. Once activated, the unit dials an are trained in first aid. Furthermore, Arbon et operator who instantly responds and contacts a al. (2011) found that among 773 respondents, friend, family member or neighbour who holds a 11 per cent had provided first aid in a RTC and, key. If none of the named responders are available, of those, 75 per cent were travelling in the vehicle then the operator will dispatch a member of their involved. They also found that first aid training team. Immediate emergency assistance can also increased the likelihood of them owning a first aid be requested. kit or pocket mask. And while our own Everyday First Aid training methodology encourages learners Though this research has shown that the to make use of everyday items and, therefore, proportions of deaths from injury which might does not rely on ownership of a first aid kit, have been survivable have remained unchanged Arbon et al.’s findings point to a readiness and in the past 20 years or more, it is important to a motivation to act. This suggests that drivers, note that the studies do not report on the levels when trained, are well placed to respond to injuries of first aid training received by the bystander or which occur on the road. passer-by and their reasons for intervening or not. Furthermore, the studies do not examine The circumstances surrounding deaths from whether intervention would have been affected falls are different from those for road deaths. The by the mechanism of injury and the level of deceased were older, and nearly three-quarters the emergency – would instances of first aid were found dead. The findings fit with data intervention have been higher in those with which suggest a growth in the size of the elderly injuries that were not as traumatic? Despite these population and the number of people living alone limitations, however, it is important to address the (The King’s Fund 2012). Unlike road deaths, findings raised in these studies in future research a passer-by or bystander seems less likely to and make recommendations for the future.

32 Are prehospital deaths from trauma and accidental injury preventable? A summary report

Are prehospital deaths from trauma and accidental injury preventable? A summary report 33 7 Recommendations he following calls for recognition are drawn from the evidence found in this research. They apply to the Red Cross, T the wider first aid training community, politicians, policymakers and others. Recognition > That the proportion of potentially preventable deaths from major trauma has remained high and unchanged in 20 years, with many more people calling 999 but not all performing simple first aid when their actions could potentially have saved someone’s life. > That first aid is an essential life skill and should be part of everyone’s basic education and integral to public health strategies, with opportunities to learn throughout one’s lifetime, particularly for those most at risk of experiencing a crisis. > That the number of deaths from falls has increased as a main mechanism of injury, while the number of road deaths has decreased.

34 Are prehospital deaths from trauma and accidental injury preventable? A summary report Recommendations for the and to advocate for acceptance of the outcome 13 first aid training community, alongside established Utstein criteria. including the Red Cross > Consider exploring our role in responding to falls, and how this might be an issue among > Encourage bystanders to take action beyond our own service users, 89 per cent of whom calling for the emergency services. The are 65 years or older and predominantly following powerful messages contained in this receiving our service because they have been research should be embedded within training recently discharged from hospital. Therefore, and awareness-raising campaigns: they may be particularly vulnerable to falls. – It is not enough to call the emergency services and do nothing else. Recommendations for decision- – Doing something is simple but life-saving: makers and policymakers maintain an open airway to keep the person Overall breathing by turning the person on their side and tilting their head back; put pressure on The UK, Scottish and Welsh Governments, a bleed to stop the flow of blood. the Northern Ireland Executive and relevant statutory bodies should ensure that the existing > Further explore people’s motivation to proceed mechanisms allow for first aid education to be with first aid interventions or not, particularly the available – for example, through schools, driving relationship between deceased and bystander, tests and public health initiatives. as this was not established in the current study. This exploration would form an evidence-based Schools understanding of the behavioural change required to alter current behaviour. > First aid should be mandatory on school curricula in England, Northern Ireland, Scotland > Continue to test out different ways of teaching and Wales. first aid education, such as blended learning, to ensure that our first aid training meets the > Government education departments, schools, needs of different learners. teachers, young people and others should champion first aid learning, integrating it > Continue to use our knowledge and expertise into existing subjects and whole-school to identify areas with a high prevalence of approaches, such as single, older households, and prioritise those communities for first aid education in order to – Physical Education and PSHE education boost community resilience, and potentially (England) prevent death and improve outcomes should community members be present to help. – Health and Well-being (Scotland) > Consider examining the role of the call handler – PSE (Wales) in supporting the bystander to perform first aid. – PDMU and Learning for Life and Work Recommendations for the Red (Northern Ireland) Cross – during assemblies, tutor time or extended learning time. > Seek to lead, along with academic colleagues, the prehospital research community to reach > The Welsh Government should integrate first consensus on what is considered ‘preventable’ aid learning into planned changes to the Welsh in the prehospital therapeutic vacuum. Given the curriculum, due to be implemented in 2018 reputation of the Red Cross within the national and obligatory for schools by 2021. and international first aid community, we are in an excellent position to draw on our substantial networks to help create space for this debate 13 This refers to a uniformed way of collecting data.

Are prehospital deaths from trauma and accidental injury preventable? A summary report 35 Driving tests Public health > The DfT should make attendance at a practical > Departments for health and relevant national first aid course with an approved provider and local public bodies across the UK should mandatory to acquire a driving licence in the work with the Red Cross and others to UK. ensure that those most vulnerable to trauma and accidental injury, such as falls, and their > The DfT should include within its Road Safety community support networks (family, friends, Statement (2015) bystander first aid as a key carers and neighbours) have the opportunity to post-crash response that can reduce the learn first aid. number of people killed or injured on the road.

36 Are prehospital deaths from trauma and accidental injury preventable? A summary report

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