Greg Smith

I do agree with the hon. Gentleman, and I will explore many of those issues later in my speech. When paramedics arrived, they found Adam cold, blue, not breathing, and without a pulse. They immediately started CPR, and took him to Harefield hospital, with the support of Thames Valley Air Ambulance. Despite the best efforts of clinicians, Adam was declared brain-stem dead on 4 February—in law, that was the moment of his death—and his heart stopped for the final time on 5 February, when life support was withdrawn. His parents, Alastair Ankers and Naomi Wakefield, both work in healthcare. Through devastating experience, they came to the conclusion that Adam’s death could have been prevented. Adam’s parents fought for more than two years for a proper, in-depth inquest, rather than the four-hour online hearing first offered. They were represented by a single barrister, paid for by remortgaging their house, against an array of solicitors and counsel for the NHS bodies and the Football Association. That is not a fair fight. The underlying condition was arrhythmogenic right ventricular cardiomyopathy—ARVC, a genetic heart disease, the first sign of which can be sudden cardiac arrest. This was a failure to identify a life-threatening emergency in real time, and it is why recognition, escalation and response matter so much. The inquest raised serious concerns about the handling of 999 calls and the ability of call handlers to recognise abnormal breathing and cardiac arrest. Ambulance services in England use one of two systems: MPDS—the medical priority dispatch system—and NHS Pathways. NHS Pathways is used by just over half of 999 services and by all 111 services in England, and it was the system used on the call that day. The inquest heard expert evidence from paramedic David Davis—not the one of this parish—who told the court, “I am unable to say that NHS Pathways as is currently configured can always properly support members of the public to identify agonal or ineffective breathing. I am also uncertain as to whether NHS Pathways can adequately identify potential out-of-hospital cardiac arrest where there is seizure-like activity at the outset.” That is about as serious a warning as an expert witness can give. If the system cannot reliably recognise the signs of cardiac arrest, people are being put in danger, and if the public are left uncertain about whether to follow the advice they are given or to act on instinct, that is a public safety problem. The coroner issued a five-point prevention of future deaths report on 16 April this year. It was addressed to 13 bodies, including NHS England, the Department of Health and Social Care, the Football Association, South Central Ambulance Service, the UK National Screening Committee and Cardiac Risk in the Young. Responses were due by 11 June. There is a pattern in those responses: every organisation expressed sympathy and described some work under way, but almost none attached a date to anything. NHS England says that a genetic service specification is “currently being revised”, but with no timetable. Staff at Resuscitation Council UK say that responsibility sits with NHS England and the Department of Health and Social Care, not them. The Association of Ambulance Chief Executives says that it is “not constituted to mandate or instruct ambulance services”. Everybody has pointed to somebody else, and there have been warnings for years about call handlers and cardiac arrest, sepsis and other conditions, with no clear public evidence of improvement. Why? I therefore ask the Minister to instruct the Care Quality Commission to urgently and regularly assess ambulance services on call-handler skill in detecting and managing abnormal breathing and suspected cardiac arrest. A CQC inspection of South Central Ambulance Service before Adam’s death had already found call handlers struggling to recognise abnormal breathing, with serious incidents leading to patient harm as a result—this is not new information to the trust. South Central Ambulance Service’s own response to the coroner’s report suggests that the public should understand that call handlers follow a fixed script, and that callers may need to act independently of the advice given. If it is genuinely the Government’s position that people in the worst moment of their life should second-guess the emergency services, the public deserve to hear that plainly, not discover it buried in a filing after a child has died. Training alone will not be enough. NHS Pathways plays a central role in how millions of emergency and urgent care calls are handled every year, yet there is strikingly little publicly available data on its safety and effectiveness. That is not good enough. Will the Minister commit to a fully independent review of the effectiveness and the culture of NHS Pathways—not simply a restatement that the National Clinical Assurance Group already provides oversight? That body assures the clinical safety of dispositions; it does not examine culture. Its terms of reference are set by NHS England and it reports to NHS England, which is the body that runs NHS Pathways. I want to press further on one other point, because it speaks to whether the Government can even get the basic facts right in responding to a dead child’s inquest. NHS England’s own prevention of future death response states that Adam was triaged through “Protocol 12, Convulsions/Fitting”—an MPDS reference. However, the coroner’s findings state that NHS Pathways, a different system owned and run by NHS England itself, was used as the script for that call. Why did NHS England’s response point to the wrong system entirely, rather than confront the failings of the system it actually runs? Did national leadership check its own response against the coroner’s findings before sending it? Will it now formally correct the record and explain how that error ever happened? Moving on, there is the question of how genetic risk is communicated within families. Distant relatives in Scotland had known since 2018 that a genetic variant, PKP2, which is associated with ARVC, ran in the family, but that was not passed to Adam’s immediate family in full until after his death, and only then because Adam’s parents themselves had to go back to that distant relative and ask directly whether there was a letter he had not shared. There was. Once the risk was confirmed, the genetic service’s answer for cascading that information further to the wider family was a brown paper envelope containing 10 photocopied letters, which the family were left to hand round themselves—a grieving family doing the NHS’s job of tracing and warning their own relatives, with no support offered. Adam’s grandmother had, in fact, raised the family history with her cardiologist at Papworth hospital, who accepted that it was recorded in three places in her notes but said he had not seen it. A 2022 referral from the GP was read by this doctor but never followed up due to an administrative error. Separately, NHS Greater Glasgow and Clyde, which held the original genetic records, refused to disclose them to the English coroner’s inquest as it fell outside its jurisdiction. The coroner considered applying to the Scottish High Court to compel co-operation, but decided against as it was not a proportionate use of public funds. No family should be told that it is not proportionate to pursue the truth about their son’s death across a devolved border. I ask the Minister to raise this issue with counterparts in the devolved health systems, so that no hospital anywhere in this United Kingdom refuses to co-operate with an inquest into a child’s death ever again.