Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0193, written 13 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 May 2015 |
|---|---|
| Reference | 2015-0193 |
| Deceased | Paul Murray |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| 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.
. ; North London Coroners Court, Her Majesty’s Coroner for the 29 Wood Street, Northern District of Greater London —Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield} Telephone 0208 447 7680 Fax 0208 447 7689 i | / : REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT [IS BEING SENT TO: Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 | CORONER ! am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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. 3 | INVESTIGATION and INQUEST On the 14” February 2013 | opened an inquest touching the death of Paul Alexander Murray , 47 years old. The inquest concluded on the 25" February 2015. The conclusion of the inquest was “Narrative”, the medical case of death was 1a Fatal cardiac dysrhythmia 1b Myocarditis. 4 | CIRCUMSTANCES OF THE DEATH Paul Alexander Murray died from the results of a myocarditis on the 8" February 2015 that was likely to have begun a day or so before. Mr Murray began to show symptoms and the first call was made to the London Ambulance Service at 12.00 . There are three matters that are likely to have a bearing on Mr Murray’s death Firstly that Mr Murray was developing the symptoms of a myocarditis such that he was vomiting and in some pain at the time of the first call to the London Ambulance Service. The Ambulance Service would not have been able to associate the general symptoms with a myocarditis. Secondly there were insufficient ambulances in circulation to respond following the second call at 12.19 if there had been sufficient ambulances and an ambulance had attended to Mr Murray it is likely that he would not have had the cardiac arrest as it is likely that had treatment been provided by the ambulance staff that treatment would have delayed the onset of Mr Murrays cardiac arrest. i : | | Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) Thirdly that had Mr Murray been taken to hospital following the call at 12.19 arriving there before his cardiac arrest it is likely that he would not have died when he did. Mr Murray did receive an emergency response by a first responder after a 4" call saying that Mr Murray had become unresponsive, a criteria that generates an emergency response. Mr Murray was taken to hospital arriving at 14:50 pm where despite treatment he died. 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. — That there were insufficient resources available for the London Ambulance service to meet the demand on the 8" February 2013 at 12.19 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 Wednesday 8" July 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Representatives of the family. London Ambulance Service | 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, abou the release or the publication of your response by the Chief Coroner. | |
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.
From the Lord Prior of Brampton
Parliamentary Under Secretary of State for NHS Productivity (Lords)
Department
of Health
Andrew Walker Richmond House
. woe 79 Whitehall
HM Senior Coroner for Northern District of Greater London London
North London Coroners Court SWIA 2NS
29 Wood Street Tel: 020 7210 4850
Barnet
ENS 4BE
. hoe 25 JUN 2015
{
Thank you for your letter to the Secretary of State for Health about the
death of Paul Alexander Murray. I am responding as the Minister with
responsibility for NHS performance policy at the Department of Health.
I was very sorry to hear of Mr Murray’s death and would be grateful if you
would pass my condolences to his family.
Your report gave details of Mr Murray’s experiences following a call to
London Ambulance Service on 8 February 2013. You were particularly
concermed that there were insufficient ambulance resources available for
the Service to meet the demand in the area at the time of the incident.
As you may be aware, it is the responsibility of individual ambulance trusts
to ensure that resources are aligned to demand. The Department of Health
continues to work closely with its partners in the healthcare system
including NHS England, Monitor and the Trust Development Authority
(TDA) to monitor and support ambulance service performance.
Furthermore, in recognition that the NHS is busier than ever, we are
backing the NHS’ future plan with an extra £8billion by 2020.
As a result of this incident, I understand the London Ambulance Service
carried out a serious incident investigation, with four consequent actions:
1. The Trust plans to increase capacity through its modernisation
programme and planning for winter, when demand increases.
2. As part of the Trust’s winter plans, “Intelligent Conveyance” is
aimed at reducing surges of demand at acute trusts.
3. The Trust is considering a process of clinical review where multiple
repeated calls report deterioration in a patient’s condition, but the category
of the call itself does not otherwise change.
4. Call takers have been reminded to free text any potentially relevant
information on calls that may be important for clinicians undertaking a
clinical review or enhanced clinical assessment.
I have also sent your report to NHS England to ensure wider awareness of
the issues you have raised. Thank you for bringing this matter to our
attention.
Te
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