Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0369, written 31 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jul 2014 |
|---|---|
| Reference | 2014-0369 |
| Deceased | Toni Skillington |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Toni Elizabeth SKILLINGTON (died 01.04.14)
THIS REPORT IS BEING SENT TO:
1. Ms Ann Radmore
Chief Executive
London Ambulance Service NHS Trust
220 Waterloo Road
London SE1 8SD
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 4 April 2014, one of my assistant coroners, Richard Ian Brittain,
commenced an investigation into the death of Toni Elizabeth Skillington,
aged 43 years. The investigation concluded at the end of the inquest on
30 July 2014. The determination I made at inquest was as follows.
“Toni Skillington took an excess of methadone and alcohol, but did not
intend to take her own life. She called family members soon after, and
they alerted London Ambulance Service, but it took almost three hours for
emergency paramedics to arrive, during which time there was a failure to
act within LAS protocols. The opportunity to attempt to save Toni
Skillington’s life was lost.
This was an accidental death.”
1
The medical cause of death was:
1a mixed methadone and alcohol toxicity
2 liver cirrhosis.
4
CIRCUMSTANCES OF THE DEATH
On the evening of Tuesday, 1 April 2014, Ms Skillington telephoned
family members including her son,
having drunk an
excess of alcohol, saying that she had taken an overdose of methadone.
(Her husband had recently died.) Ms Skillington had been prescribed
methadone in the past, but by that time not for a year.
telephoned London Ambulance Service (as did Ms
Skillington’s brother) at 7.30pm and explained the situation, including the
fact that he was not with his mother at that time.
The call handler did not know that methadone is a narcotic and did not
ask her supervisor, so marked it as an overdose of “other”. The call was
prioritised as C2, with a target response time of 30 minutes.
As this was an extremely busy night with a staff shortage, no ambulances
were available for C2 calls, so two ring backs were made to make welfare
checks, at 8.21pm and 9.42pm. There was no reply on either occasion.
According to operational procedures, this should have prompted the
following steps.
- A call to local hospitals to check if the patient had arrived by other
means.
- Validation of the contact details and address displayed on the
screen.
- An alert to the police of a possible collapse behind locked doors.
- Notification to the clinical hub to consider upgrading the call.
None of these steps was taken following either of the two ring backs.
A paramedic team leader did response profile the call at 8.56pm, but he
was not told of the fact that a ring back had been made with no reply. If
he had, he would have upgraded the call immediately. In the event, he
put a clinical flag on the call, intending to return to this when he had
reviewed all the calls being held. However, he then attended to other
duties and so the call was not upgraded.
A new call allocator came on duty at 9.30pm, and made a further welfare
check at 9.54pm. When she received no reply, she dispatched one and
then another vehicle. When each of these was diverted to a red call, she
dispatched a third at 10.11pm and asked that the call be upgraded, which
it was, ensuring that the vehicle was not diverted.
2
This call allocator also gave evidence that if she had been on duty earlier,
she would have upgraded the call sooner.
An ambulance finally arrived at Ms Skillington’s home at 10.24pm and
gained entry ten minutes later, but the crew found her already dead.
5
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. The Medical Priority Dispatch System (MPDS) does not include
methadone as a one of the drug choices following an overdose,
despite the fact that it is commonly taken in excess. I understand
that the LAS has written to the National Academy for Emergency
Medical Dispatch about this.
2. The MPDS does not ask specifically whether the patient is alone,
though it is recognised that this renders a patient particularly
vulnerable. I understand that the LAS has also written to the
National Academy for Emergency Medical Dispatch about this.
3. Two welfare checks were made via ring backs without any reply
gained, yet neither of these was followed by the appropriate action.
Even accepting how busy and under staffed the service was that
night, a call could at least have been made to the police asking for
attendance.
4. London Ambulance Service received a call describing an
intentional methadone overdose, taken with alcohol, and yet no
paramedic responded until three hours later.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 29 September 2014. I, the coroner, may extend
the period.
3
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
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
NHS England
Ms Skillington’s son
I 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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
31.07.14
4
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