Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0102, written 18 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 | 18 Mar 2015 |
|---|---|
| Reference | 2015-0102 |
| Deceased | Grant Benson and Gordon Davidson |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Community health care and emergency services related deaths |
| Organisation named | North East Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Yorkshire Ambulance Service. 1 CORONER I am Andrew Tweddle Senior Coroner, for the coroner area of County Durham and Darlington. 2 CORONER’S LEGAL POWERS I 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. (see attached sheet) 3 INVESTIGATION and INQUEST On 22nd August 2014 I commenced an investigation into the deaths of Grant Thomas Benson, age 21 and Gordon Nicky Davidson, age 26. The investigation concluded at the end of the inquest on 18th March 2015. The conclusion of the inquest was Road Traffic Collision. Gordon N Davidson’s cause of death was given as 1a) Traumatic Injuries related to a Road Traffic Accident and Grant T Benson’s cause of death was given as 1a) Immediate Effects of Fire related to a Road Traffic Accident. 4 CIRCUMSTANCES OF THE DEATH Both deceased were travelling in a motor vehicle which crashed and hit a tree. The passenger died either at the time of the collision or soon thereafter. The driver survived the initial impact and died in the ensuing fire. CORONER’S CONCERNS 5 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. – Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone. The evidence was clear that in cross boundary area situations there are inadequate systems in place to secure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summond, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe 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 14th May 2015.I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Yorkshire Ambulance Service. I have also sent it to , Durham Constabulary, County Durham and Darlington Fire Brigade and North East Ambulance Service who may find it useful or of interest. 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 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. 9 [DATE] [SIGNED BY CORONER]
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.
Safest People, Safest Places County Durham and Darlington Fire and Rescue Service This matter is being dealt with by: | | mz ext: . Fire and Rescue Service Headquarters, pate 23 April 2015 Belmont Business Park, Durham, DH1 1TW Our Ref: a Your Ref: Chief Executive: Susan Johnson Mr Tweddle Senior Coroner HM Coroners Office PO Box 282 Bishop Auckland County Durham DL14 4FY Dear Mr Tweddle, Following the Regulation 28 Report to Yorkshire Ambulance Service dated 19 March 2015, County Durham and Darlington Fire and Rescue Service (CDDFRS) have conducted a review of policies and procedures for liaising with over the border Blue Light Services when incidents occur on or near those adjoining borders. The concerns raised in the Regulation 28 Report have been considered and our comments are below. 1 Inability to Dispatch Resources without Identifying Exact Location on Mapping System In December 2014 CDDFRS introduced a new state of the art mobilising and communications system into their emergency control room. Prior to the introduction of this system control personnel would extract incident location information from callers using interrogation techniques given to them during initial training and induction. The new system with its integral mapping system displays an approximate location of the caller which is based upon the triangulated position of the cell phone in use. This not only allows a fire appliance to be despatched to a more accurate location than previously but it also allows the control operator to view the possible location of the incident and use it to extract more accurate information from the caller. Policy dictates that, if control operators are unable to get an exact location from the caller, resources must be mobilised to initial location information whilst operators continue to interrogate the caller to gain further information. Should the location displayed on the map indicate that the incident is on or near the border of another emergency service area the fire control operator would inform the appropriate emergency service immediately using a priority telephone contact number. se Moy, x; Sofe/< x Stonewall Ee) Ws EQUALITY DIVERSITY CHAMPION www.ddfire.gov.uk Saye ea Tel: (0845) 305 8383 Fax: (0191) 386 6353 Minicom: (0191) 384 7524 Failure to Record All Communications Audio, whether it be radio or telephony is recorded at all operator workstations; the recording is activated as soon an operator opens up an audio channel at that workstation. Under normal circumstances emergency calls are monitored by a Supervisor thereby creating a dual record of the call at both operator positions. Recordings are kept indefinitely. Urgent Advice from a More Local Agency County Durham and Darlington FRS have good working relations with adjoining Fire and Rescue Services and would where necessary ask for further advice regarding location information whilst, where appropriate, keeping the caller on the line. Policy dictates that control operators must immediately inform other emergency services where it is indicated that their services may be required. Transferring Calls from One Emergency Service to Another Currently it is not technically possible to transfer an emergency call from one emergency service to another. When calls are received in error for another Emergency Service, the Fire Service control room will log the call and take as many details from the caller as possible; at the same time another fire control operator will inform the relevant emergency service. Where necessary, and as appropriate, control operators will continue to speak to callers until it ts known that assistance, from the attending emergency service, has arrived at the incident. Communications between Emergency Services Although primary communications with other emergency services is via the telephone there are a number of other contact paths available: e Airwave radio hailing channels, monitored at all times in the control room (other Fire & Rescue Services) e Airwave radio hailing channel (North East Ambulance Service) e Airwave radio hailing channel (Durham Constabulary) e Email e Fax Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality. Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services. Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and Ambulance Trusts outlining changes to the way calls would be processed in the future, this included exchanging and updating all direct primary access telephone numbers for each adjoining emergency control room. As mentioned previously there are already good communication protocols and effective mutual assistance arrangements in place between each of the five adjoining Fire and Rescue Services. In addition CDDFRS have remote buddy arrangements in place with Leicestershire Fire and Rescue Service who will, where necessary, take calls for CDDFRS and pass them back to the control via agreed routes. These buddy arrangements only come into force if spate conditions, usually associated with adverse weather conditions, affect the whole of the North East Region. Yours sincerely Assistant Chief Fire Officer
North East Ambulance Service NHS NHS Foundation Trust Our ref: HMC 900 Ambulance Headquarters Your ref: AT.DF.1499/1500.14 Bernicia House The Waterfront Private & Confidential Goldcrest Way — Mr Tweddle Newburn Riverside H.M. Coroners Office Newcastle upon Tyne PO Box 282 NE15 8NY Bishop Auckland County Durham Tel: 0191 430 2000 DL14 4FY Fax: 0191 430 2086 41th June 2015 Dear Mr Tweddle, RE: Gordon Nicky Davidson and Grant Thomas Benson, deceased Following from the Regulation 28 report and recommendations sent to Yorkshire Ambulance Service and bordering emergency services. | can confirm that the North East Ambulance Service has undertaken a review of our own processes and systems in tespect of cross-border incidents. The Regulation 28 Report raised a number of concerns, which are shown below alongside the specific response from our review. 1. Inability to dispatch without identifying exact location on mapping system. The Trust uses northings and eastings co-ordinates to map the location of calls alongside a Gazetteer pulling addresses from telephone landlines. Currently it is being reviewed as to the feasibility of increasing the frequency of Gazetteer and map updates for all Ambulance Trusts. 2. Failure to record all communications. The Trusts contact centre systems record (NICE call recording system) the following = €xternal calls = Airwave radio conversations The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). For more information visit www.cqc.org.uk 6. Is it not possible for one ambulance service to dispatch an ambulance from another ambulance service? Whilst we would not dispatch an ambulance from another service via our systems, we would make direct contact and request that another service dispatch a resource under ‘mutual aid’ agreements. In the event of an emergency call being on or near a border and the Trusts response time is likely to exceed the target in life threatening cases. The Trust would contact the bordering ambulance service to request assistance. This approach is custom and common practice with our colleagues in Yorkshire, Scotland and the North West. The wider principle of ‘interoperability’ is a key priority for all emergency services and is being driven within ambulance services by the National Ambulance Resilience Unit (NARU) and the Association of Ambulance Chief Executives (ACCE). This work sees regular joint service exercises for which the Trust regularly attend. 7. Review of call handling procedures All relevant information has been passed to our training department to review our call handling procedures and ensure any gaps are identified and acted on. We are however confident that the existing procedures are robust. Yours sincerely pp Ordo Pe Head of Risk and Regulatory Services The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). For more information visit www.cqc.org.uk
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