Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0226, written 9 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Sep 2013 |
|---|---|
| Reference | 2013-0226 |
| Deceased | Martin Daffydd Barker |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health 2. North West Ambulance Service 3. Manchester Medical Services CORONER lam Joanne Kearsley, Area Coroner, for the coroner area of Manchester South. CORONER’S LEGAL POWERS and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST investigation concluded at the end of the inquest on 05/09/13. The conclusion of the [ of Misadventure. 4 | CIRCUMSTANCES OF THE DEATH the Warehouse Project in Trafford which is a venue which runs events on weekends he was pronounced deceased at Salford Royal. His cause of death was confirmed as 1a) MDMA toxicity. Following Mr Barker's death concerns were raised by the Resus Unit at Salford Royal Hospital. On arrival at the hospital Mr Barker was in cardiac arrest, however the Resus en route with a patient can call to notify the hospital so that they can be ready anticipating their arrival and the patient is categorised as either a ‘Red’ or ‘Amber’ Category according to their seriousness. 4. Salford Royal Hospital NHS Trust oyal Hospit ee | | make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 On 14/12/12 | commenced an investigation into the death of Martin Daffydd Barker. The inquest was that the deceased died as a result of MDMA toxicity and | recorded a verdict | On the 9th December 2012 the deceased was ona night out with friends. They attended between September and January. There are approximately 5000 people who attend the In addition in this case, at 3am (which was the time Mr Barker arrived at the hospital) the Resus Reception Desk is not always staffed as the receptionist has other responsibilities arrest, the receptionist was not at her desk and Manchester Medical Services did not CORONER'S CONCERNS have the keypad code in order to access the door. On this occasion security staff happened to be passing and were able to assist in gaining entry. Manchester Medical Services are one of a growing number of independent medical providers. They are contracted to provide medical cover at large events, approximately 900 per year throughout the UK. Many of the events invoive in excess of 10,000 people. They have as part of their medical cover ambulances to transport people to hospital should this be required. At the Inquest | heard evidence from Salford Royal Hospital, Manchester Medical Services and North West Ambulance Service. All confirmed in evidence to me that this was potentially a national problem and that there was no clear guidance or policy in place nationally or locally. Salford Royal indicated that it was their understanding from event planning meetings which had taken place in 2011 around the Manchester Pride event that the position was that independent providers such as Manchester Medical Services should, if they are on the way to hospital with a critical patient, ring North West Ambulance Services who would then telephone the relevant hospital and notify them of the impending arrival. It was clear that up to present there has been a refusal to provide independent providers with the telephone number so that they can use this directly. It was somewhat unclear whether this refusal to disclose the number was by the NHS Trusts or North West Ambulance Service. There were understandable concerns that the number should be used appropriately and that there should be a uniform approach to classifying patients as ‘Red’ or ‘ Amber (this simply being a North West Ambulance Service classification.) The Director of Manchester Medical Services gave evidence and indicated that this issue is raised by them at every planning meeting they attend for major events. However they are consistently refused the pre alert telephone number. It was also the understanding of Manchester Medical Services that despite previous discussions North West Ambulance Service will not act as an intermediary to place the pre-alert call through to the relevant NHS Trust as the independent ambulances are not on the NWAS system. He indicated in evidence that the only time NWAS will place a pre-alert call is if they have their own crews at an event together with the independent providers and a member of NWAS places the call into their operators. Since this incident Manchester Medical Services have made further attempts to obtain the pre alert telephone number to no avail. He also confirmed that an ideal situation would be not to involve NWAS but for them to be able to use the number directly. Angela Lee, Sector Manager for NWAS, then gave evidence and she indicated that it was her understanding that NWAS would act as an intermediary for the independent medical providers to place calls through to NHS Trusts to alert them and that NWAS would not want the telephone number directly provided to other medical service providers, although she could not explain the rationale for this. She also indicated that she would expect NWAS to then triage the patients over the telephone in accordance with NWAS policies and to categorise them in line with NWAS categorisations. This was somewhat surprising given that NWAS will not have any contact with the patient and are in no way involved in their transportation to hospital. What was agreed by all who gave evidence was that there are no written policies locally or nationally and that all would be greatly assisted by the same. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 1. There appears to be no national guidance on how independent national providers of medical services (particularly those covering large scale public events) can put NHS hospitals on standby for incoming urgent patients, something which is normal procedure for the regional ambulance services. 2. There is confusion as to whether the independent providers should place a call to the regional ambulance services who would then act as “gatekeeper” in forwarding this information to the respective hospital. 3. Without clear guidance there is a risk that the most critically ill people who are being transported to hospital are at risk as the hospitals have received no pre- alert, have not had the opportunity to place teams on standby and are not expecting their arrival. 4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to. 6 | ACTION SHOULD BE TAKEN In my opinion there should be local if not national written policies as to how NHS Trusts are placed on pre-alert by independent medical providers and this should be clearly distributed to all concerned as a matter of urgency. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04/11/13. |, the coroner, may extend the period. 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons ar | have also sent it tof of Greater Manchester Police who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. J 9 | Date: Signed by: P/Fa8
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Coroners Manchester South 13 January 2014 Chief Coroner's Office 11th Floor Thomas More Royal Courts of Justice Strand London WC2A 2LL Our ref: JSP/KA/02665-2012 Your ref: Dear Sirs RE: Martin Daffydd BARKER (Deceased) | enclose herewith a copy of the letter | have received from the Rt. Hon Jeremy Hunt MP in response to my Regulation 28 Report. Yours faithfully The Coroner's Court, Mount Tabor, Mottram Street Stockport SK1 3PA Senior Coroner john.pollard@stockport.gov.uk Area Coroner joanne.kearsley@stockport.gov.uk Tel: 0161 474 3993 Fax: 0161 474 3994 From the Rt Hon Jeremy Hunt MP RG Secretary of State for Health | Department of H ea It h Richmond House 79 Whitehall London SWIA2NS POC1_807571 “Tel: 020°7210 3000 Ms J Kearsley Mb-sofs@dh.gsi.gov.uk Area Coroner Coroner’s Manchester South The Coroner’s Court Mount Tabor Mottram Street eso Stockport SKI 3PA 20 DEL 2013 Des Mas, Weess ley ? Thank you for your letter following your inquest into the death of Martin Daffydd . Barker, I am sorry that you did not receive an earlier reply. In your report you detailed the circumstances around Mr Barker’s death following ingestion of MDMA. In the early hours of 10 December 2012, Mr Barker was assessed as requiring emergency admission to hospital and transferred to Salford Royal Hospital in an ambulance run by the independent provider, Manchester Medical Services. Upon arrival at the hospital Mr Barker was in cardiac arrest. I understand from your report that the Manchester Medical Services ambulance crew had neither the telephone number which goes directly to the emergency resuscitation area of Salford Royal hospital, nor the code to allow them to gain entry once they had arrived. Consequently, there was a delay in providing treatment for Mr Barker. Concluding your report, you raised concerns about guidelines for independent providers and Trusts covering access to appropriate numbers and codes which would prevent incidents like this occurring in future. I am satisfied that meetings and discussions that have taken place locally involving Manchester Medical Services, Salford Royal NHS Foundation Trust and the North West Ambulance Service, as set out in their responses to you, will help to ensure that a similar situation does not arise again with these organisations, Turning to the wider picture, doors at hospitals are often locked to ensure the safety and security of staff and patients at times when very little activity is expected. It would not be reasonable to allow unrestricted access to all areas of the hospital, particularly when few staff are on duty overnight. As you will appreciate, independent providers of ambulance services do not fall directly within the remit of the Department of Health. They are however required to register with, and be inspected by, the Care Quality Commission. I therefore propose to share this case with the CQC so that they can consider whether adequate arrangements for access to emergency departments need to be part of the inspection portfolio for such organisations. Patients might reasonably expect independent ambulance providers to have in place arrangements to access emergency departments to which they might be required to take patients, and that reasonable access should be granted. Furthermore, public events are required to comply with the Health and Safety Executive (HSE) Event Safety Guide, which is a guide to health, safety and welfare at music and similar events. The guide covers arrangements for emergency care and transfer. Plans for such events must be approved by the local authority and, depending on the overall risk score, should be assessed by the NHS ambulance service - even where the NHS is not providing the medical cover, I therefore intend to write to the HSE to bring this case to their attention, Responsibility for licensing, including arrangements for medical cover at events, sits with local authorities. It should, for example, be possible for HSE to amend the Purple Guide to indicate more explicitly the arrangements that need to be in place for independent ambulance services to contact and access receiving emergency departments. It may be reasonable that local authorities should satisfy themselves that this has been adequately addressed before granting an application, However this would ultimately be a matter for the HSE to decide. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Barker’s death to my attention. YA sine Ay JEREMY HUNT
North West Ambulance Service NHS NHS Trust OUR REF:INQ/C/GM/13/288 Headquarters YOUR REF: JK/KA/02665-2012 Ladybridge Hall 399 Chorley New Road Heaton, Bolton BL1 50D Tel: 01204 498400 Fax: 01204 498422 DIRECT TEL:01204 498 444 Joanne Kearsley Area Coroner Coroner's Manchester South Mount Tabor Mottram Street Stockport SK1 3PA www.nwas.nhs.uk 18 October 2013 Dear Area Coroner Kearsley, INQUEST INTO DEATH OF MARTIN BARKER DATE OF RESUMED HEARING: 05 SEPTEMBER 2013 | write further to your letter of 9 September 2013, enclosing a Regulation 28 Report. Please accept this as our response in accordance with Regulation 29(4). | note you raise the following concerns regarding these matters:- 1. There appears to be no national guidance on how independent national providers of medical services (particularly those covering large scale public events) can put NHS hospitals on standby for incoming urgent patients, something which is normal procedure for the regional ambulance services. 2. There is confusion as to whether the independent providers should place a call to the regional ambulance services who would then act as “gatekeeper’ in forwarding this information to the respective hospital. 3. Without clear guidance there is a risk that the most critically ill people who are being transported to hospital are at risk as the hospitals have received no pre-alert, have not had the opportunity to place teams on standby and are not expecting their arrival, 4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to. Whilst the North West Ambulance Service (NWAS) accepts that that the Regulation 28 Report was appropriately issued, given the matters raised in evidence at the inquest, we make the following comments, with reference to the concerns outlined above. % Firstly, it is important to note the difference between organised events, such as Manchester Pride, where NWAS has overall responsibility for the co-ordination of emergency ambulance response, and the day to day operation of ambulance services, both NHS and private. In the case of sty, 4 Chairman: Mrs MWhyham MBE gf “y INVESTORS | | 3, W/E f your: Bronza & = Chief Executive: Mr D Hurrell rd IN PEOPLE |? Asa Delivering the right care, at the organised events, arrangements will be agreed locally as part of the planning of the event, as, clearly, each event is different and involves different parties. We believe that the agreement between Manchester Medical Services (MMS) and NWAS, made specifically in relation to the Manchester Pride 2011 event, which was that priority calls should be directed through the NWAS control room, who would then put the relevant NHS hospital on standby, if necessary, has spilled over into the day to day running of services, resulting in MMS being unable to directly place NHS Hospitals on standby. Where such agreements are in place, or where private ambulance services are operating in close operation with NWAS, we would expect | standby calls to be routed through NWAS. | In relation to the day to day operation of private ambulance services, it is our position that NWAS should not, and cannot be, the “gatekeeper” for NHS hospital standby numbers. These numbers are owned by the hospitals and it is a matter between them and MMS, or any other private ambulance service providers, as to whether or not the number is shared. We submit that guidance from the Department of Health may assist in relation to these matters. If you require any further information please do not hesitate to contact me. Yours sincerely a Head of Legal Services oe |
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