Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0268, written 21 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2013 |
|---|---|
| Reference | 2013-0268 |
| Deceased | Mark Stephen Smith |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Community health care and emergency services related deaths |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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. London Ambulance Service Legal Services London Ambulance Service NHS Trust 220 Waterloo Road London SE1 8SD 1 CORONER | am Andrew Walker, senior coroner for the coroner area of Northern District of Greater London 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 28" Day of March 2013 | commenced an investigation into the death of Mark Stephen Smith aged 52 years old. The investigation concluded at the end of the inquest on 16" October 2013 . The conclusion of the inquest was a narrative conclusion Mark Smith having died of Zopiclone and Mirtazapine overdose complicated by ethanol use with chronic obstructive pulmonary disease and coronary artery atheroma under paragraph 2. On the 2" March 2013 Mr Smith telephoned for an ambulance having intentionally taken more of his medication than the dose prescribed by his doctors. There was a delay from 8.57 and 53 seconds, when an ambulance should have reached Mr Smith, to 11.18 and 17 seconds when the ambulance arrived to assist Mr Smith. This delay was the result of a recognised mismatch between capability and demand and on the 2 March 2013 between 3am and 2pm there were 15 and 20 ambulances short pan-London. This delay was likely to have contributed to Mr Smith’s death. 4 | CIRCUMSTANCES OF THE DEATH Following Mr Smith’s call to the London Ambulance Service the Emergency Medical Despatcher obtained the correct determinant for the response ,(a response under 30 minutes). When taking a call from a person threatening suicide and who is alone, as Mr Smith was, the instruction within the operating procedure OP060 is that the fact that the caller is alone should be documented and the Emergency Medical Despatcher should stay on the line with them where possible. The Emergency Medical Despatcher did not note that Mr Smith was alone and did not stay on the line with Mr Smith. Had these steps been taken it may have been possible to recognise at an earlier stage when Mr Smith, who, although the Emergency Medical Despatcher did not know this, had taken medication that would render him unconscious within 30 to 45 minutes. This significance of this would be that had Mr Smith fallen unconscious and the Emergency Medical Despatcher had known this the call would have been upgraded to a response within 8 minutes. CORONER’S CONCERNS 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. — Consideration to be given to giving guidance on what “where possible” in the terms of the above section of OP060 and whether a supervisor should be consulted before the decision is taken not to stay on the line where a person has taken an intentional overdose and is alone. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17" December 2013. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons AvMA (representing members of the family) and ns of Eastwoods Solicitors (representing | 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 o he believes may find it useful or of interest. You may make representations to me, the boroner, at time of your response, about the release or the publication of your r “E Chief Coroner. 24 OCT 2013
See every Prevention of Future Deaths report matching London Ambulance Service NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.