Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0101, written 17 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Mar 2015 |
|---|---|
| Reference | 2015-0101 |
| Deceased | Kevin Hoey |
| Coroner | William Morris |
| Coroner area | Cambridgeshire (North & East) |
| Category | Community health care and emergency services related deaths |
| Organisation named | East Midlands Ambulance Service NHS Trust · East of England Ambulance Service NHS Trust |
| 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.
William Reade Morris Senior Coroner for North & East Cambridgeshire wh REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: East of England Ambulance Service NHS Trust (EEAST) 1 CORONER | am William Reade Morris, Senior Coroner for North & East Cambridgeshire CAT RADALEDIOTESAT DADO m™-0___—=EEeeeo=s$$| 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 16/07/2014 | commenced an investigation into the death of Kevin Patrick Hoey, 55 . The investigation concluded at the end of the inquest on 12 March 2015. The conclusion of the inquest was Narrative conclusion - The deceased was Kevin Patrick Hoey. Shortly after 6pm on the 14th July 2014 the deceased at his home at Regate Villa, Foul Anchor, Tydd Gote, Wisbech was suffering from chest pain and an ambulance was called. He was attended in due course by paramedics from both East Midlands Ambulance Service and East of England Ambulance Service. Reading from ECGs were taken and blood pressure recorded. Clinical review has established the deceased should have been treated as time-critical and taken to hospital. This did not happen and the deceased was incorrectly assessed as appropriate to leave at home. Early in the morning of the 15th July 2014 members of the deceased's family discovered his condition had severely deteriorated. An ambulance was called and in due course he was attended by paramedics from East of England Ambulance Service. Death was pronounced at 02.43 at his home address and the cause of death has been 1a) Haemothorax and 1b) Acute aortic dissection. Haemothorax Acute Aortic Dissection 4 CIRCUMSTANCES OF THE DEATH 7 Kevin Hoey was aged 55 years and had complained of chest pains whilst painting the exterior of the house. An ambulance was called at around 1840hrs and he was diagnosed with a panic attack. Ambulance called again when pain increased. Paramedics attended and resuscitation was unsuccessful. Death was confirmed at 0243hrs by Paramedic ay 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. — East of England Ambulance Service NHS Trust should liaise with East Midlands Ambulance Service NHS Trust in relation to training under the EMAS Paramedic Pathfinder Programme, identifying whether a patient is suitable for treatment in the Community or requires hospital transfer, with a view to East of England Ambulance Service NHS Trust considering introduction of training similar to that under the EMAS Paramedic Pathfinder Programme. Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambs, PE29 3PA Tel 0345 045 1364 | Fax 01480 372777 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you EEAST 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 28 April 2015. |, 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 copy of my report to the Chief Coroner and to the following Interested Persons Legal Representative for EMAS and The Hoey Family. | 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. Dated 17 March 2015 Signature Coll Senior Coroner for North & East Cambridgeshire Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambs, PE29 3PA Tel 0345 045 1364 | Fax 01480372777
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.
Our reference : Date : 28 April 2015 Mr William Morris Senior Coroner for North and East Cambridgeshire Registration and Coroners Services Lawrence Court Princes Street Huntingdon PE29 3PA Dear Mr Morris, Ambulance Headquarters Melbourn Station Whiting Way Melbourn Cambs SG8 6EN 0845 6013733 I write further to an email received from Coroner’s Officer, on 19 March 2015, to which she attached a Regulation 28 Report to Prevent Future Deaths. This report was made by you following the inquest into the death of Kevin Hoey, which concluded on 12 March 2015, and recommended that the Trust consider introducing training similar to East Midlands Ambulance Service NHS Trust (EMAS) in line with their Paramedic Pathfinder Programme. Prior to the inquest, one of the Trust’s Clinical Managers had already met with our EMAS colleagues and discussed the Paramedic Pathfinder Programme, with a view to suggesting that the Trust consider implementing this training. The Trust welcomes any improvements to support paramedics in their decision making and will be reviewing this case to ensure that learning is embedded to mitigate any chance of this being repeated. The Trust would respectfully like to point out that in a case where the initial patient assessment and history taking was completed by another healthcare professional from EMAS, the EEAST clinicians would have taken a professional steer from this first clinical contact. Whilst the Trust recognises this may have ultimately contributed to this patient’s tragic deterioration, the Trust does acknowledge that the primary assessment had already been undertaken by a registered professional. Following your recommendation, the Paramedic Pathfinder Programme has been discussed at the Trust’s Clinical Quality and Safety Group (CQSG), which is attended by the Locality Directors and a number of senior clinical managers. As Chair of CQSG, I requested that the Paramedic Pathfinder Programme be reviewed by a group of clinicians to scope out how this could be implemented within the Trust and what the implications are to our current training programme. This piece of work is currently ongoing. I would be happy to update you further once this review has been completed. Please do not hesitate to contact me should you require any further information in the meantime. Yours sincerely, Director of Nursing and Clinical Quality Chief Executive: Dr Anthony C. Marsh QAM SBStJ DSci (Hon) MBA MSc FASI Chair: Sarah Boulton
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