Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0271, written 21 Nov 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 Nov 2013 |
|---|---|
| Reference | 2013-0271 |
| Deceased | Daniel Maurice McMahon |
| Coroner | Andrew Walker |
| Coroner area | London |
| Category | Railway related deaths |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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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. Metropolitan Police General enquiries Metropolitan Police Service New Scotland Yard Broadway London SW1H O0BG 2. Department of Health Ministerial Correspondence and Public Enquiries Unit Department of Health Richmond House 79 Whitehall London SW1A 2NS 3. RSSB Enquiry Desk RSSB 1 Torrens Street London, EC1V 1NY 4, LAS 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 13" Day of January 2102 | commenced an investigation into the death of Daniel Maurice McMahon aged 30 years old. The investigation concluded at the end of the inquest on 23 September 2013. The conclusion of the inquest was a narrative conclusion; the medical cause of death was head injuries. On the 11" January 2012 Daniel Maurice McMahon suffered severe head injuries as a result of being hit by a train at Willesden Junction Station, Station Approach. Daniel had been on leave from Park Royal Hospital whilst undergoing treatment under the Mental Health Act. The Jury concluded that, on the balance of probabilities the train could have been stopped in time if the correct information regarding the location had been entered, (by police taking the call from a member of the public) CIRCUMSTANCES OF THE DEATH Mr McMahon has been seen by a member of the public falling from a bridge over a section of the over-ground railway track next to Willesden Junction London Underground Station. Mr McMahon was seen to strike the overhead cables and then fall onto the track, Mr McMahon then moved under the bridge but still in the line of sight of the member of the public who by now was on his mobile phone talking to police. Mr McMahon appeared to move in front of, and was struck by a train leaving Willesden Junction Station sustaining fatal injuries. The Court appointed expert was of the view that, despite the fatal injury received by Mr McMahon from the collision, it was potentially dangerous to use bilateral needle decompression of the chest, currently performed where necessary by the London Ambulance Service, without a valve. 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. — (1) Metropolitan Police :- That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track, This is in addition to the attendance location and the incident location normally recorded when a 999 call is made. (2) Department of Health:- Consideration to be given to using a feedback form, where a patient is on $17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up (3) RSSB:- The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line. (The current position would be to set the signals to caution). (4) London Ambulance Service:- The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR 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 Tuesday 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 | 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 respgnse by the Cfjef Coroner. par Cad 21 OCT 28
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.
London Ambulance Service NHS NHS Trust Executive Office Headquarters 220 Waterloo Road London SE1 8SD Tel: 020 7783 2038 Fax: 020 7783 2053 Mr A Walker Senior Coroner for the Northern District of Greater London North London Coroner’s Court 29 Wood Street Barnet ENS 4BE Our reference : INQ6806/12 9 December 2013 Dear Mr Walker Daniel Maurice McMahon : Regulation 28 Report to Prevent Future Deaths I am writing in reply to the Regulation 28 Report to Prevent Future Deaths dated 21 October 2013, made under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquest into the death of Daniel Maurice McMahon which was heard at North London Coroner’s Court between 23 September and 4 October 2013 (inclusive). The report brings to my attention your concerns following the evidence of the court appointed expert in relation to the use of bilateral needle chest decompressions without a valve. As you will be aware, the LAS had available a senior paramedic prepared and able to give evidence on the issue of needle chest decompressions at the inquest but this witness was not called. The LAS have reviewed the matter and | hope that you find the following explanation helpful: Purpose of needle chest decompression Needle Chest Decompression forms an important part of the management of chest trauma in the pre hospital environment by paramedic staff. This procedure has the potential to vent pressure from within the thoracic cavity which may occur where the lung collapses and there is an increasing build up of pressure within the chest. This condition is described as a tension pneumothorax. This condition can ultimately displace the heart, great vessels and neighbouring lung causing progressive respiratory and circulatory collapse with catastrophic consequences if left untreated. In a permissive environment such as a hospital, formal drainage of the thoracic cavity would be undertaken by inserting a chest drain with an underwater seal in situ. In a patient who is undergoing positive pressure some enhanced pre hospital teams would undertake an open thoracostomy to allow drainage of the thoracic cavity under pressure. These are not options that are available for use by the majority of paramedic staff and therefore needle chest decompression has formed the mainstay of treatment for addressing potential tension pneumothoraxes. Warner’ et al. in their 2008 study looking at the safety of needle chest decompression concluded that the use of needle chest decompression appears to be a safe procedure when performed by paramedics in an urban EMS system. In this study pre hospital needle chest compression resulted in four cases of unexpected survival. Procedure for needle chest decompressions The classic method of needle chest decompression involves the insertion of a 14 gauge cannula (1.6mm) into the 2"4 intercostal space just above the third rib in the mid clavicular line. The needle / trocar is then removed and the plastic cannula left in situ and allowed to vent the chest cavity. This technique is described in both the American College of Surgeons Committee on Trauma Advanced Trauma Life Support Manual? (which is endorsed by the Royal College of Surgeons of England) and in the Pre Hospital Trauma Life Support Manual. Neither of these seminal texts on the emergency management of trauma recommends the use ofa one way valve. The American College of Surgeons Committee, Pre Hospital Trauma Life Support Manual actively discourages the use of one way valve citing that there is a negligible chance of inducing an iatrogenic pneumothorax as the port created by the needle chest decompression is very much smaller in diameter than the trachea which will act as the preferential air passage. It also cites that a makeshift solution of attaching the finger of a medical glove with tip removed, as suggested in evidence by your expert, is likely to be fiddly and delay definitive care. The consensus statement from the Faculty of Pre Hospital Care of the Royal College Surgeons Edinburgh (2007) on the Management of Chest Injuries* makes no mention of the use of one way valves in the section on needle chest decompression. Conclusion Both before and after the inquest, this matter has been discussed at some length within the Medical Directorate of the LAS. The Medical Director of the LAS and one of our Senior Paramedics took the opportunity to review our practice with Surgeon Commander Leigh Smith, an extensively published author on needle chest decompression and expert on the management of thoracic trauma, and concluded that the current approach of the LAS (and UK ambulance services) is appropriate in respect of not using one way valves on needle chest decompressions. ieir J. Warner, BS}*, Michael K. Copass, MD? and Eileen M. Bulger, MD! Use of Needle Thoracostomy in the Prehospital Environment 2008, Journal of Pre Hospital Emergency Care Vol. 12, No. 2, Pages 162-168 2 American College Surgeons, Committee on Trauma. ‘Advanced Trauma Life Support (2012) 9* Edition 3 american College Surgeons, Committee on Trauma. Pre Hospital Trauma Life Support (2011) 7" Edition 4 Caroline Lee, Matthew Revell, Keith Porter, Richard Steyn (2007) The pre hospital management of chest injuries: a consensus statement. Faculty of Pre-hospital Care [Royal College of Surgeons of Edinburgh, Emergency Medical Journal 24:220~224. doi: 10.1436/emj I hope that you will be assured by the consideration the LAS has given to your report, and by the actions taken to investigate the areas you have raised. My Medical Director, Fionna Moore, and | would be happy to meet with you to discuss this further if that would be useful. Yours sincerely hun Katie Ann Radmore Chief Executive
ae Department of Health POCI_ 817376 Mr A Walker Senior Coroner North London Coroner’s Court 29 Wood Street Barnet London EN5 4BE Dey he, wieibe, From the Rt Hon Jeremy Hunt MP Secretary of State for Health Richmond House 79 Whitehall London SWIA 2NS Tel: 020 7210 3000 Mb-sofs@dh.gsi.gov.uk Thank you for your letter following the inquest into the death of Daniel Maurice McMahon. In your report you state that Mr McMahon died from head injuries after being struck by a train leaving Willesden Junction Underground Station. At the time of his death, Mr McMahon had been on leave from Park Royal Hospital while undergoing treatment under the Mental Health Act. I understand the London Ambulance Service will reply to you directly on your concern about their crew’s use of a decompression needle without a valve. In your list of concerns you ask that the Department of Health considers: e using a feedback form, where a patient is on leave under S17 of the Mental Health Act, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties the patient has whilst on leave are picked up. In relation to the care of mental health patients, we would advise that everyone referred to secondary mental health services should receive an assessment of their mental health needs. If it is agreed that the person’s needs are best met by a secondary mental health service, a care plan should be devised. Services should aim to develop one assessment and care plan that will follow the service user through a variety of care settings to ensure that correct and necessary information goes with them. In reviewing a care plan as part of discharge planning from hospital or other residential settings, appropriate liaison with mental health services in the community is essential. The period around discharge is a time of elevated risk, and particularly of self-harm. This underlines the need for thorough review and assessment prior to discharge and effective follow-up and support after discharge. Mental health trusts should ensure that individuals with higher support needs are identified and appropriately supported. All care plans must include explicit crisis and contingency plans. This includes arrangements so that the service user or their carer can contact the right person if they need to at any time with clear details of who is responsible for addressing elements of care and support. We are currently reviewing the advice in the “Code of Practice Mental Health Act 1983”. This includes reviewing the chapter on leave of absence under section 17 of the Mental Health Act 1983 and the references to care planning. The experience of this case will be used to assist that review. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr McMahon’s death to my attention. Gr srw we we JEREMY HUNT
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