Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0162, written 10 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2014 |
|---|---|
| Reference | 2014-0162 |
| Deceased | Terence Dooley |
| Coroner | Jean Harkin |
| Coroner area | Manchester City |
| 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 This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being sent to: e North West Ambulance Service - Brother and Next of Kin Chief Coroner Counsel Coroner | am Jean Harkin, H.M. Assistant Coroner for the area of Manchester City. 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. Investigation and Inquest On the 7th January 2014 | commenced an investigation into the death of Terence Norbert Dooley, aged 45 years. The investigation concluded at the end of the inquest on 7th January 2014. The cause of death was found to be: 1a __ Ingestion of excessive amounts of Citalopram, Mirtazapine and Propanalol The conclusion of the inquest was as follows: Narrative conclusion: Terence Norbert Dooley was found deceased on 29th October 2013, having taken a fatal dose of medication. Due toa heavy demand on the Ambulance Service, attendance to him was delayed by 2 hours 38 minutes. Circumstances of death Mr Dooley had taken an overdose of tablets and he telephoned 999 for an ambulance, informing the call handler that he had taken a mixture of 40 tablets. He complained of feeling hot and said that he could not feel his legs. He gave his location as being on a bench next to Butler Bridge by the canal. He was able to name the tablets he had taken and was informed that a response car would be with him in 20 minutes. However, it was 2 hours 38 minutes later when a response vehicle was dispatched. By the time the response vehicle arrived Mr Dooley had wandered off. On the evidence heard in court, he most likely entered the water io cool down. He was found on the bank by the canal, wet with wrinkled skin and unresponsive at 0800hrs. He had called the service at 0151hrs. 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. Despite the fact that each different tablet could be fatal on its own, let alone together, this call was given a code green. 2. This was an emergency and a delay of 2 hours and 38 minutes is totally unacceptable regardless of pressures on the service due to Halloween. 3. There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes. 4. The computer generated codes are misleading. One death is one too many when it should have, and could have been avoided. Action should be taken In my opinion action should be taken to prevent future deaths and | believe that your organisation has 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 6" Jun 2014. 1, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, PP 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 oo Interested Persons: Mi the brother of the deceased, and Ambulance Service. , Counsel to the | 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. MLO NEHK. Mrs Jean Harkin Date: 10" April 2014 H.M. Assistant Coroner — Manchester City area
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.
North West Ambulance Service NHS| NHS Trust OUR REF: INQ/C/GM/13/258. Headquarters YOUR REF: Ladybridge Hall DIRECTTEL: 01204 498.444 399 Chorley New Road Heaton, Bolton BL1 5DD Mrs Jean Harkin Tel: 01204 498400 H.M. Assistant Coroner Fax: 01204 498423 HM Coroner's Office pou DU Manchester City Area PO Box 532 Manchester Town Hall Albert Square Manchester M60 2LA 2 June 2014 Dear Mrs Harkin TERENCE DOOLEY (DECEASED) We write further to your letter of 10 April 2014, enclosing a Regulation 28 Report to Prevent Future Deaths in relation to the inquest examining the death of Terence Norbert Dooley. Please accept this as our response in accordance with Regulation 29(4). We note that you raise concerns regarding the following: The coding of the call; The delay in an ambulance attending; A lack of communication; and NWAS computer generated codes being misleading. BS be) DD) Le Coding of the call All emergency calls received by the North West Ambulance Service (NWAS) are processed utilising the Medical Priority Dispatch System (MPDS), which is a system used both nationally and internationally. MPDS determines the priority in which vehicles should be dispatched based upon the immediacy of the life threatening symptoms displayed by the patient, as reported by the caller. MPDS provides a unified system used to dispatch appropriate aid to medical emergencies and includes caller interrogation and pre-arrival instructions. The caller’s responses to scripted questions are inputted to elicit a response output category (chief complaint). Each call is also assigned a sub-category, or code. This code indicates the priority with which vehicles should be dispatched. The Department of Health (DH) and local commissioning arrangements assign one of six response categories to the individual codes produced by MPDS, which generate the following resource response times: Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton. BL1 50D ty Hay, gy INVESTORS on $Me Po we IN PEOPLE | Champion Wer Delivering the right care, at the right time, in the right place e Red 1 and Red 2— response within 8 minutes (75% of the time) — DH target; e Green 1 and Green 2— vehicle response within 20 minutes (95% of the time) — local target; e Green 3 — telephone triage within 60 minutes (100% of the time by the Urgent Care Desk) — local target; and e Green 4 - telephone triage within 60 minutes (100% of the time) or a vehicle response within 4 hours — local target. During the 999 call made by Mr Dooley on 28 October 2012 he advised that he had taken an overdose of medication. The Emergency Medical Dispatcher (EMD) confirmed that Mr Dooley was conscious and breathing and the system generated a Green 2 response code. MPDS is designed to elicit priority symptoms from a caller, for example, whether the patient is alert, conscious and breathing. If a patient has a compromised airway or is in cardiac arrest the system recognises that they require immediate, life sustaining, treatment and will generate a Red response code. Had Mr Dooley indicated any of these priority symptoms MPDS would have generated a higher response code. Whilst clearly extremely serious, an overdose of medication is not necessarily immediately life threatening (compared to a cardiac arrest, for example) and so will not generate a Red response, without additional clinical symptoms such as unconsciousness or a change in the patient’s colour. NWAS have conducted a full audit of this call and can confirm that Green 2 was the correct code. Response time We note that you acknowledge in your inquest conclusion that there was a heavy demand on the Ambulance Service on 28 October 2012 and we can confirm that this was an extremely busy night for NWAS. At 00.03 on 28 October 2012 the Greater Manchester Duty Control Centre Manager reported that there were 35 incidents waiting. By 01.22, this had increased to 50 incidents and by 01.39 NWAS had 62 emergency incidents outstanding. NWAS has a finite number of vehicles available at any one time and are aware that demand for vehicles fluctuates. We are acutely aware of the importance of delivering safe patient care, are constantly striving to improve our procedures and have a number of contingency plans which can be implemented during busy periods. One such procedure is Emergency Operations Centre Procedure EOC006 (0006), which is designed to optimise patient care during periods of high demand. In these instances, a resource responding to a lower priority call may require standing down to attend an incident with a higher priority, for example: © Red 2 calls diverted to Red 1 calls; e Green 1 & 2 calls diverted to Red 1 or 2 calls; and ® Green 3 or 4 calls diverted to Red 1, Red 2, Green 1 or Green 2 calls. Between 26 October 2012 and 28 October 2012 NWAS received 3301 calls in which patients were displaying immediately life threatening symptoms (Red 1 and Red 2 calls) and responded within national targets. We believe that sustaining this level of response, when dealing with exceptionally high demand, demonstrates the effectiveness of our policies in ensuring that the maximum possible number of patients receive the appropriate level of care. We can confirm that 0006 was implemented and in force during 27 and 28 October 2012. In spite of this, regrettably, there were still no vehicles available to send to Mr Dooley until 03.20, as they were all responding to immediately life threatening emergencies. Lack of communication We note that you state the following as a matter of concern: “There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes.” Whilst the EMD would no doubt have been aware of NWAS’s target of a 20 minute response to Green 2 calls, she at no point indicated to Mr Dooley that a vehicle would be dispatched within this period. The EMD in fact explained to Mr Dooley that NWAS were responding to a high number of life threatening emergencies at that time and advised him to call 999 back if he felt any worse. We therefore do not accept that there was any lack of communication during this incident. Computer generated codes In December 2013 NWAS served a witness statement from Acting Emergency Operations Centre Sector Manager, which clearly explained the codes generated by the MPDS system. [EM also gave evidence at the inquest and was therefore available to answer any questions or provide any further explanation about the meaning of the codes, how they are generated, or the MPDS system in general. We therefore respectfully disagree that the computer generated codes are misleading. We hope that the content of this letter has satisfactorily addressed your concerns. If you require any further information please do not hesitate to contact us. Yours sincerely Acting Head of Legal Services
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