Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0357, written 16 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2013 |
|---|---|
| Reference | 2013-0357 |
| Deceased | Clive Gould |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
Inquest into the death of Clive GOULD
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT JS BEING SENT TO:
Chief Executive, South Central Ambulance Service
4 | CORONER
' lam Nicholas Graham, Assistant Coroner, for the Coroner area of Oxfordshire
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2008 |
| and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
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| INVESTIGATION AND INQUEST
On 22 July 2013 an investigation commenced into the death of Clive Gould, who was 76
| years old. The investigation concluded at the end of the inquest on 11 December 2013.
| The narrative conclusion of the inquest was that Mr Gould died on the morning of 18 |
| | July 2013 and that an ambulance was called at 4:18am but did not arrive until 5:47am, |
the medical cause of death being Congestive Cardiac Failure.
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4 | CIRCUMSTANCES OF THE DEATH
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Mr Gould had a complex past medical history of small cel! lung cancer,
pulmonary embolism, vasculitis, interstitial lung disease, emphysema, atrial
fibrillation, hypertension, eft ventricular dysfunction and previous bladder |
cancer.
He was receiving chemotherapy for his lung cancer and had last received
treatment on 17 July 2013.
During the early hours of 18 July he awoke complaining of sickness and
shortness of breath and his wife rang the ambulance at 4:18am. Despite five
foltow up calls the ambulance did not arrive until 5:47am.
Sadly, Mr Gould had gone into cardiac arrest by the time the ambulance arrived |
and could not be revived.
5. At 6:22am death was confirmed.
During the course of the inquest the evidence revealed matters giving rise to concern. In
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| 5 | CORONER’S CONCERNS
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| | my opinion there is a risk that future deaths will occur unless action is taken. !n the
circumstances itis my statutory duty to repart to you.
The MATTERS OF CONCERN are as follows. —
(1) The original call made by IJ was atlocated a priority green status which
ambulance would be diverted, which is what happened on two occasions, An
| meant that should a higher priority call be received (a red status call) then an
internal audit of that call suggests that a different priority could have been Given to |
the original call and the presenting concerns of Mr Gould's status.
| recommend that SCAS review how they allocate priorty to calls such as this one
and identify whether any improvements to the allocation of priority should be given.
(2) In evidence before the inquest SCAS indicated that there was little resilience in the
system to tolerate absence or sudden sickness of personnel at certain times.
My recommendation is that SCAS look at the resilience, particularly in rural areas,
to consider whether further resources may need to be deployed
(3) The evidence from the family at the Inquest was that they were informed that an
ambulance would be arriving shortly. Had they known that there was to be the
delays that occurred because other calls had been given priority, they informed me |
that they could have used first aid resources availabie to them within the village, |
such as locally trained first aiders etc.
My recommendation is that SCAS review what information they give callers and to
consider whether communication in relation to estimated times of arrival should be
notified to callers or the possibility of delays.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action. My recommendations in respect of
reviews to be carried out are set out above.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by the 10 February 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
I have sent a copy of my report to the Chief Coroner and oT -:- of the
Interested Persons.
lam 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.
Dated: 16 December 2013
Ww Ayn
Nicholas Graham, Deputy “Coroner {
Nm
1 response 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.
South Central Ambulance Service A/T E9 NHS Foundation Trust 7 And 8 Talisman Business Centre Talisman Road Bicester Oxfordshire OX26 6HR Mr Nicholas Graham Assistant HM Coroner for Oxfordshire Tel: 01869 365161 Oxfordshire Coroner's Office The Oxford Register Office 2™ Floor 1 Tidmarsh Lane Oxford OX1 4NS 7° February 2014 Dear Mr Graham Clive Gould Date of death: 18" July 2013 Inquest held at Oxford Coroner's Court on 11" December 2013 Thank you for your letter o dated 16" December to which | have been asked to further investigate and reply to three concerns raised by the Coroner during the course of the inquest on the 11" December 2013. The Coroner recommended that SCAS review the following three concerns: Concern 1 How SCAS allocate priority to calls and identify whether any improvements to the allocation of priority should be given SCAS response Currently SCAS operates the Department of Health licenced 999 triage software system called AMPDS. As this is a licenced tool all ambulance responses are determined at a national level. As a Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes. The AMPDS product has been developed by Priority Dispatch Corporation with a comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on a monthly basis. As we currently use AMPDS our Call Takers are required to ask a pre-determined set of verbatim questions. Therefore to comply with AMPDS licence the Call Takers are required to adhere to the scripts and responses to these pre-determined questions by callers will directly affect the response level assigned to the patient. SCAS have recognised that AMPDS is a dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health. The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014. Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR Concern 2 SCAS /ook at the resilience, particularly in rural areas, to consider whether further resources may need to be deployed SCAS response A review has been undertaken of overnight cover aid Rapid Response Vehicle cover has now been extended to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. This will provide additional resilience against short term sickness and wider geographical deployment cover in rural areas overnight. Rota match versus demand has also been reviewed with crew's now starting duty earlier in the morning to bridge an identified gap. The forecasting demand approach has continued to develop and is working within reasonable levels of tolerance of accuracy enabling resources to be effectively planned. We are aiso about to commence co-responding pilots with the Fire Service in both Oxford and Buckinghamshire which will further enhance our capacity to respond particularly in the rural areas. Concern 3 SCAS review what information they give callers and to consider whether communication in relation to estimated times of arrival should be notified to callers or the possibility of delays SCAS response SCAS has reviewed this point and conclude that as our 999 service is a dynamic response service, situations and priorities can change and diverting of resources to a more time critical incident can happen and must take priority. Currently no ambulance service communicates at the time of a call what their response time will be for this reason. SCAS have recognised that on occasions patients may experience a delay in response due to high levels of demand. In order to support patients SCAS have developed a Clinical Support Desk (CSD) within Emergency Operations Centre who will call back and support patients with further clinical advice until a response is on scene. The CSD are very experienced nurses and can support these patients and their families. | hope this helps to clarify our current arrangements-and improvements at SCAS and if you need any further information please do not hesitate to make contact. Yours sincerely Deve 7 ae . Director of Quality and Patient Care
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