Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0202, written 27 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 | 27 May 2015 |
|---|---|
| Reference | 2015-0202 |
| Deceased | Yusuf Abdismad |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) |
| 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
Yusuf ABDISMAD (died 02.01.15)
THIS REPORT IS BEING SENT TO:
1. Dr Fionna Moore
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 5 January 2015, I commenced an investigation into the death of Yusuf
Abdismad, aged 5 years. The investigation concluded at the end of the
inquest on 19 May 2015. I made a determination of death by natural
causes.
4
CIRCUMSTANCES OF THE DEATH
Yusuf died from meningococcal septicaemia. His mother called 999 at
10.42am on 2 January 2015. Following assessment by the emergency
medical despatcher, she was advised to call 111. She did so and then at
some point during that call, the 111 service called 999 again. By the time
the London Ambulance Service arrived, Yusuf was in cardiac arrest.
1
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.
In attempting to gain an answer to the question, “Is the patient awake
(conscious)?” the emergency medical despatcher first asked “Is Yusuf
awake?” When Yusuf’s mother replied “no”, the EMD went on to ask “Is
he conscious?”
This seems a confusing way of approaching this very important question.
If a person is asleep, then one cannot know if they are conscious without
waking them. If the answer to the question “Is he awake?” is “no”, then
the most obvious follow up to that would appear to be, “Can you wake
him?”
Yusuf’s mother was by now panicking and erroneously replied “yes” to
the question of whether Yusuf was conscious, though she had not tried to
wake him. The EMD assumed that Yusuf was asleep but rousable, which
in fact is unlikely to have been the case.
There were other difficulties with the call, such as the EMD’s failure to
recognise that a description of scratches all over might actually refer to a
rash, missing the description of pupils no longer visible, and not thinking
about the possibility of meningitis. These have, I was told at inquest,
been addressed by training, but I remain concerned that such a method
of attempting to elicit whether the patient is conscious or unconscious
might be used by other EMDs.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and 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 27 July 2015. I, the coroner, may extend the
period.
2
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
Association of Ambulance Chief Executives (AACE)
National Ambulance Service Medical Directors (NASMeD)
NHS England
Yusuf’s mother
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
27.05.15
3
Regulation 28: Prevention of Future Deaths report
Yusuf ABDISMAD (died 02.01.15)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
London Central & West Unscheduled Care Collaborative
(LCW UCC - NHS 111 service provider)
St Charles Hospital
Exmoor Street
London W10 6DZ
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 5 January 2015, I commenced an investigation into the death of Yusuf
Abdismad, aged 5 years. The investigation concluded at the end of the
inquest on 19 May 2015. I made a determination of death by natural
causes.
4
CIRCUMSTANCES OF THE DEATH
Yusuf died from meningococcal septicaemia. His mother called 999 at
10.42am on 2 January 2015. Following assessment by the emergency
medical despatcher, she was advised to call 111. She did so and then at
some point during that call, the 111 service called 999 again. By the time
the London Ambulance Service arrived, Yusuf was in cardiac arrest.
1
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.
During the 111 call, Yusuf’s mother said at one point that Yusuf was not
breathing. Rather than responding to this as a red flag that required
immediate paramedic attendance and asking for London Ambulance
Service to be notified, the LCW call handler felt she wanted to probe
further.
Evidence in court from the 111 service was that call handlers would
benefit from further training in recognising agonal breathing. I appreciate
that 111 is not intended as an emergency service, but they are likely from
time to time to take calls that are or become urgent.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and 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 27 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
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
Yusuf’s mother
2
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
27.05.15
3
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