NASMeD Best Practice guidance
Conveyance of children by operational ambulance clinicians in face-to-face settings
July 2021
Background
The conveyance policies relating to children amongst the UK ambulance services vary considerably.
Many trust policies were originally based on the letter from the RCPCH sent to ambulance trusts in
2009 that recommended that all children under the age of 2 should be conveyed, however some
trusts have moved away from this and have adapted local policies based on reviews of incidents
including safeguarding incidents. This best practice guidance supersedes the RCPCH letter 2009 and
is aimed at assisting ambulance services in developing their local paediatric procedures around
conveyance.
In June 2019 the HSIB issued a safety recommendation to AACE:
‘It is recommended that the Association of Ambulance Chief Executives agrees guidance that can
inform its members on the competency and authority for staff to convey, refer and discharge children
under five years who are subject to 999 calls.’
In July 2020 a workshop was held involving ambulance trust paediatric leads. The workshop agreed a
number of principles that have helped inform this best practice guidance.
The definition of children in this guidance is up to the age of 18 years old.
This guidance is applicable where non conveyance is considered after a face-to-face assessment has
been made by ambulance clinicians.
The underlying reasons for caution around a decision not to convey a younger child to hospital after
an ambulance has been called have not changed in that:
• significant illness and injury can be harder to diagnose in very young children
• underlying safeguarding issues can often be equally difficult to appreciate initially
Key principles
• All non registered clinicians and newly qualified paramedics (NQPs)
MUST follow local trust
guidance before discharging
any child.
• Some clinicians (for example advanced and specialist paramedics) may have received
additional education in the care of children and should follow local guidance around
conveyance.
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• Supported clinical decision making should be encouraged and wherever possible should be
with a more senior Health Care Professional (HCP) (ideally with additional paediatric and/or
specialist expertise e.g., GP, 111 integrated care, Clinical Advisory Service or paediatric
community or palliative team).
• When referring to another HCP, discussions involving the child and their carer should be
encouraged, with the use of video consultation or speaker phone considered.
• Ambulance clinicians speaking/referring to another HCP should inform them of their skill
level, particularly if they are non-registered clinicians - in line with local procedures.
• Ambulance clinicians referring to a HCP have a responsibility to provide accurate information
so they can agree the most appropriate outcome. This will include all relevant clinical
information including history taking and clinical assessments/observations. HCPs giving
advice or accepting referrals will rely on the information they are provided with by the
attending ambulance clinician.
• There must always be an accurate record made in the patient care record of any discussions
and referrals to another HCP including details of any agreed care plan and follow up
including actions to be taken in the event of subsequent deterioration.
• If non accidental injury (NAI) is suspected children must always be conveyed. NAI should be
considered in children presenting with an injury, particularly in children aged under 5 years.
Where the injury is not consistent with the age of a child (e.g. bruising in a non-mobile child)
or there are other concerns of NAI this should prompt a full examination of the patient
including skin exposure to look for bruising or other signs of potential NAI. Refer to JRCALC
safeguarding guidelines and local Trust guidance.
• All children must be conveyed if they may have been exposed to potentially toxic
substances, including button batteries or magnets.
• All children not conveyed to hospital must be left in the care of an appropriate adult who
has parental responsibility for the child (such as a parent or guardian).
• All staff should be encouraged and supported to use ‘Spotting the Sick Child’ as an
educational resource to maintain their skills - an interactive tool commissioned by the
Department of Health and Health Education England to support health professionals:
https://spottingthesickchild.com/
Children with mental health presentations/refusal of advice or conveyance
All children must be conveyed or referred for further assessment if they have signs of mental health
crisis, suicidal thoughts or self-harm unless a mental health practitioner has made a full assessment
and (i) recommends that conveyance is not required and (ii) there is agreement between
professionals that an alternative pathway is both safe and desirable.
Where possible health care records should be accessed to establish if the child is known to any
services, and if any care/crisis plans exist.
If the parent/legal guardian refuses, against advice, the conveyance of the child to hospital the
ambulance clinician must speak to another HCP for a plan to be agreed. Ideally that HCP will know
the child or young person, will be from their mental health team, or could also be their own GP. In
some cases, it will be necessary to arrange a Mental Health Act assessment though the existing
pathways in each trust.
If the child or young person is deemed to have mental capacity then the clinician should speak to
another HCP before discharging and document this discussion.
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Some young people, particularly those over the age of 16 may be able to engage in interventions
with a mental health professional that help to manage the immediate crisis.
Refer to local ambulance trust policies around consent, refusal and mental capacity in children.
Conveyance to hospital
All children under age one – any child with an identified (or suspected) injury or illness
must be
conveyed to the nearest Emergency Department (ED) which accepts children or else referred via a
well governed and agreed local trust pathway (for example referred to a GP for a further clinical
assessment).
Where clinical assessment finds no evidence of injury or illness, the request for ambulance help may
be to address underlying social concerns or undisclosed parental stress or illness and therefore the
child should either be (i) conveyed to ED or (ii) the ambulance attendance should be notified to the
patient’s GP as a minimum.
Age 1 years to 5 years- after face-to-face clinical assessment by a registered HCP this age group can
be considered for handover of care and not conveyed to hospital.
If considered for non conveyance all clinicians
must make a direct referral to another registered HCP
as per local trust procedures. In most cases, during working hours, this will be the patient’s own GP
but out of hours may be via NHS111. A care plan or further follow up
must be agreed at this point. If
non conveyance is agreed, the receiving HCP will accept the handover of care and transfer of clinical
responsibility at this point.
Age 6 to 17 years- after face to face clinical assessment by a registered HCP this age group can be
considered for discharge or referral. The patient’s GP should be informed of the child’s need for an
emergency ambulance attendance. Where the ambulance clinicians require the support of another
HCP to avoid conveyance to ED this may be via the patient’s own GP or other routes such as NHS
111, as per local procedures.
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