Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0385, written 22 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Sep 2015 |
|---|---|
| Reference | 2015-0385 |
| Deceased | Stuart Knight |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| 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.
Y 1 Noy) 18 DONE HM CORONER Central Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: i Ev -cica Director, East Midlands Ambulance Services CORONER | am Stuart P G Fisher, Senior Coroner, for the coroner area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincolnshire, PE23 5JE. 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 29 August 2014 | commenced an investigation into the death of Stuart Knight. The investigation concluded at the end of the inquest on 26 August 2015. The conclusion of the inquest was that Mr Knight died as a result of an accident, the medical cause of death being: Ja. Head Injury with Subarachnoid Subdural Haemorrhage and Skull Fracture 2. Alcohol Excess aad Oi 4. CIRCUMSTANCES OF THE DEATH In the early hours of 29 August 2014, Mr Knight was lying in a road ‘in Wainfleet. Initially he appeared to be unconggi immediately made a 999 call and requested the attendance of an ambulance. call was timed at 00:04:32, he was informed that the ambulance service was busy and that there would be a delay in their arrival. This call was never cancelled. stated that some minutes after he made his initial call to the ambulance service Mr Knight (who was apparently intoxicated) managed to stand up. went on to state that he then observed Mr Knight fall backwards hitting his head on the road with significant im i aused a loud "popping" sound and resulted in Mr Knight becoming snconsoou ill cons was such that at 00:24 he made a further call to the ambulance service and outlined details of Mr Knights fall. Although spoke with ambulance personnel on the telephone it was not until 01:15 that a Fast Response Vehicle arrived at the scene. It appeared that the Paramedic in the FRV assessed Mr Knights condition and then spoke on the radio to the ambulance service requesting the attendance of a double-crewed ambulance which did not arrive at the scene until 01:28. In summary, from the time thal ace his first call to EMAS it took 1 hr and 11 mins for the | FRV to arrive at the scene and 1 hr and 24 mins had elapsed between the 1“ call being made and the arrival of the double crewed ambulance. Mr Knight was taken to Pilgrim Hospital and arrived at 02:02 and died later that day. 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. — (I) Significant and unacceptable delays occurred in despatching an ambulance to a patient who was unconscious and had clearly suffered a serious head Injury. Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS. (Il) (II!) (IV) (Vv) 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 November 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (a) 7 (daughter of deceased). lam 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. Senior 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.
East Midlands Ambulance Service NHS Trust Emergency Care | Urgent Care | We Care Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk Mr Stuart P G Fisher HM Senior Coroner Central Lincolnshire Lindum House 10 Queen Street Spilsby Lincolnshire PE23 5JE 2 November 2015 Dear Mr Fisher Re: Report to Prevent Future Deaths : Stuart Knight (DECEASED) | am writing in response to your Regulation 28 Report to Prevent Future Deaths, dated 22™ September 2015, bringing to my attention the Coroners concerns arising from the inquest into the death of Stuart Knight. Firstly, can | begin by assuring you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. Assurance around the availability of an ambulance in a timely manner to those requiring emergency aid is at the heart of our purpose Your report and Prevention of Future Death notice pertaining to the inquest into the death of Stuart Knight stated the following in relation to the service provided by EMAS to Mr Knight: Significant & unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS | have included some additional detail, including our record of the chronology in relation to our care of Mr Knight in a detailed response in the enclosed appendix, However, | also wanted to respond to the specific points you have raised and have set these out in the following paragraphs, which | trust is helpful in providing the assurance you seek. East Midlands Ambulance Service NHS Trust Emergency Care | Urgent Care | We Care Background East Midlands Ambulance Service (EMAS) serves a resident population of 4.8million across the East Midlands region (Derbyshire, Leicestershire and Rutland, Lincolnshire (including North and North East), Northamptonshire and Nottinghamshire), across 6,425 square miles. Each year we respond to over 616,000 emergency and urgent calls. Allocation of response Calls to Ambulance services are coded to medical priority, matching government criteria. In addition every ambulance service is required to report on response times to each type of call. A summary of this requirement is detailed in appendix 1. In response to the issues raised at the inquest into the unfortunate death of Mr Knight we would respectfully submit the following points as actions we are taking to improve our service :. 1. Investment in Staff East Midlands Ambulance Service has made significant investment in both staff and vehicle resources since 2014 in both “frontline” staff who attend 999 calls but also in staffing within the emergency operations centre. This recruitment has been supported with investment in our education centres to facilitate training from Emergency Care Assistant, through Ambulance Technician and ultimately to Paramedic level. Staff work on allocated rota lines with a percentage (around 12% in Lincolnshire) working on relief where they can be deployed flexibly to work shifts where expected demand exceeds our core rota deployment output. In this way extra resources can be deployed dynamically to ensure availability through periods of predicted high demand. 2. Fleet Provision In addition we have invested in our fleet provision to increase the number of vehicles we have available allowing the trust to deploy more resources at any one time. A comparative summary of our staffing and fleet provision from August 2014 to the current year is detailed in appendix 2. 3. Clinical Tools to support staff We have supported our frontline staff with the introduction of Paramedic Pathfinder (PP). PP is a pre hospital assessment guide based around the widely used NEWS (National early warning system) designed to assist crews to identify patients that are suitable for onward referral as opposed to transport to the emergency department. Typically when a patient is not conveyed from their home address (See and Treat), the job cycle time (total time the ambulance is dealing with that particular call and is therefore unavailable) is reduced. Starting in April 2014, by October 2015 94% of staff have completed the training. For the longer term this translates into a project based on Commissioning for Quality and Innovation (CQUIN) money to develop specialist pathfinder tools for specific conditions ultimately to identify and East Midlands Ambulance Service NHS Trust Emergency Care | Urgent Care | We Care develop referral services to accept these patients and thus negate the need to transport the patient to the emergency department. This will ultimately increase “see and treat” levels.and reduce job cycle time. 4. Clinical Assessment Team We have invested significantly in the scope of our Clinical Assessment Team (CAT) based in the emergency operations centre. The CAT team are a group of clinicians, qualified Paramedics and Nurses, who work within the EOC on a 24 hour a day 7 day per week rota. They work providing support and telephone assessment to 999 calls received by the trust. The result of the telephone assessment can, in some serious cases, ensure that a call is dealt with as a higher priority due to clinical need or, in other cases, result in the call being dealt with to a conclusion by the CAT clinician. This is termed as “hear and treat”. In dealing with calls in this manner this ensures that frontline resources are not sent if not required therefore making them available to mobilise to patients with more serious clinical need that require immediate treatment or transport. As a direct comparison of August 2014 and August 2015 within Lincolnshire an additional 1200 calls were dealt with via hear and treat negating the need for face to face consultation therefore increasing ambulance availability. 5. Specific Initiatives As a local initiative between the Trust and the commissioning group in east Lincolnshire, a single Ambulance Technician vehicle is available to be deployed dynamically to calls where a traditional double crewed ambulance may not be required, for example a non-injury fall requiring assistance. Supported by the CAT team this resource can suitable respond to a call and through CAT refer or discharge at scene, again negating the need for an ambulance to be deployed. The scheme covers both the Skegness and Boston areas and has run from April 2015 with the following attendances. On average this initiative allows around 40 calls per month to be appropriately and safely assisted, referred and discharged without the need for the attendance of an emergency ambulance. A summary of both our “hear and treat” and the CAT car initiative activity can be seen in appendix 3. Through local initiative, central trust-wide strategy and CQUIN funded project work; the continued emphasis of the Trust is to make ambulances available to those with a high clinical need. This is accomplished by both increasing staff numbers and vehicles to ensure there are enough resources available at any given time. Similarly initiatives are in place and being developed to ensure that calls received not requiring an ambulance attendance are dealt with safely and appropriately in alternative ways that do not add unnecessary demand onto emergency staff and vehicles. We hope that the significant investment in our front line resources which we are working to complete by March 2016 should reduce the chances of the significant delays that occurred in this unfortunate case. | trust that this information is helpful but please do not hesitate to contact me if you require anything further. Yours sincerely Sue eyes, ¢ : Sue Noyes Chief Executive
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