Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0022, written 15 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jan 2016 |
|---|---|
| Reference | 2016-0022 |
| Deceased | Jasmine Lapsley |
| Coroner | Nicola Jones |
| Coroner area | North West Wales |
| Category | Community health care and emergency services related deaths |
| Organisation named | Welsh Ambulance Services NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
Nicola Jones Assistant Coroner for North West Wales REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE WELSH AMBULANCE NHS TRUST FIRST MINISTER MR CARWYN JONES, WELSH ASSEMBLY GOVERNMENT HEALTH MINISTER MR MARK DRAKEFORD, WELSH ASSEMBLY GOVERNMENT CHAIRMAN AND CHIEF EXECUTIVE EMERGENCY AMBULANCE SERVICE COMMIT- TEE FOR WALES CORONER | am Nicola Jones, Assistant Coroner for North West Wales 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:/Awww. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 21/08/2014 | commenced an investigation into the death of Jasmine Ruby Lapsley. The investigation concluded at the end of the inquest on 12 January 2016. The conclusion of the inquest was that Jasmine’s death was due to an accident. The medical cause of death was 1a. Choking. CIRCUMSTANCES OF THE DEATH On 19 August 2014 6 year old Jasmine Lapsley was on holiday with her family at a property in Morfa Nefyn on the Lleyn Peninsula in the County of Gwynedd. At 20.30 hours Jasmine choked on a grape. Her father [EEE tried to dislodge the obstruction immedi- ately by backslaps and the Heimlich Manoeuvre. Jasmine stopped breathing and was un- responsive. At 20.31 hours Jasmine’s grandmother ran 999 and spoke to Ambulance Control at 20.32. The call was registered at 20.34 hours. The call was correctly classified as RED 1, the most serious requiring attendance without delay. The response time for Welsh Ambulance NHS Trust arriving at RED 1 patients is to arrive at 65% of patients with- in 8 minutes. The nearest two ambulances at Pwllheli, some 7 miles away were not available. The next nearest available ambulance was dispatched at 20.33. This was at Porthmadog , 20 miles and some 24 minutes from Morfa Nefyn. The roads between Morfa Nefyn and Porthmadog are winding, narrow and down to one lane in many places. Ambulance Con- trol contacted Community First Responders in Morfa Nefyn but all calls went to voicemail. At 20.35 two Community First Responders contacted Ambulance Control to confirm that they could attend and were mobilising. They were some 7.5 miles and 19 minutes away. Community First Responders are unpaid volunteers trained by Welsh Ambulance NHS Trust (WAST). They are trained in basic first aid and are equipped with defibrillators and other essential equipment to maintain an airway and perform CPR and keep a patient alive until an ambulance or other WAST resource arrives. Community First Responders are a valuable resource in rural and remote areas. Under current arrangements when they are available they inform Ambulance Control. There is no formal rota system ensuring contin- uous cover in all areas. The method for contacting CFRs is generally by mobile telephone which is not a reliable form of communication in rural and remote areas due to the patchy 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217 availability of networks. During the Inquest the Manager of Ambulance Control gave evidence that had the 999 call been received at 6 pm then the Air Ambulance would have been dispatched immediately given the gravity of the situation. Wales Air Ambulance is a charity which exists solely as a resource for WAST. It is classed as a WAST resource. It is clear that the incident involving Jasmine required the immediate dispatch of Air Support. Wales Air Ambulance only flies between 7 am and 7 pm. There was no WAST resource Air Support available for Jasmine. It is the practice of Ambulance Control to go through all WAST resources to ascertain whether they can assist before contacting alternative support. This was the reason given by WAST for not contacting the RAF 22 Squadron Search and Rescue helicopter until 20.46, 13 minutes after the original 999 call. They were already airborne and proceeded straight to Morfa Nefyn. Whilst the 999 call was in progress a neighbouring off duty police man attended and com- menced CPR, shortly followed by his wife, an employee of WAST and a first aid trainer. They relentlessly carried out appropriate CPR in an attempt to resuscitate Jasmine. Some air was entering her lungs as evidenced by the rise and fall of her chest. It is likely by this stage that the grape was no longer fully occluding the airway and was dislodged to some extent by back slaps. At 20.45 a local fire crew were flagged down by a family member and assisted briefly in CPR before the neighbours took over once more. This CPR continued until the ambulance arrived. The Community First Responders attended at 20.54 hours. The ambulance was logged by Ambulance Control as being 200 metres away at 20.57. The RAF aircraft arrived within minutes of the ambulance. Jasmine was transferred from the ambulance to the aircraft and airlifted to Ysbyty Gwynedd, Bangor. She arrived in the Emergency Department at 21.33. Despite of the best efforts of the clinicians at the Emergency Department to resuscitate Jasmine the decision was made to withdraw treatment and Jasmine sadly died at 23.58 hours. RAF 22 squadron Search and Rescue helicopter were often called to assist WAST when WAST were unable to attend to retrieve and/or treat patients. Unless involved already in their primary duty of Search and Rescue the RAF always assisted WAST. The duties of RAF Search and Rescue in North West Wales were transferred to a private company Bris- tows in 2015. Bristows continue to assist WAST as the RAF did previously. WAST had no Protocol, Memorandum of Understanding or Standard Operating Procedure to formalise or govern the relationship between WAST and RAF. The position remains the same with Bris- tows. This is not a reliable resource for WAST as is only available when not engaged on their primary duty of search and rescue. There is no obligation upon them to assist in any event. 37 Castle Square, Caernarfon, Gwynedd, LLS5 2NN Tel 01286 672804 | Fax 01286 675217 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 circum- stances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) There is no reliable WAST Air Support in North West Wales during the hours of 20.00 hours and 07.00 hours, those being the hours not covered by Wales Air Ambulance or the recently introduced Emergency Medical Retrieval Teams. WAST should review this gap in air support which an essential asset in accessing, treating and retrieving critically ill or injured patients, particularly in remote and/or rural areas. (2) There is no effective rota system for Community First Responders to ensure consistent cover by these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Re- sponders to ask them to attend an incident is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication. (3) Given the difficulties in ambulances arriving at many rural and/or remote areas in North West Wales it is essential that there are sufficient local Community First Responders to ar- rive promptly at the casualty and provide essential treatment preserving life until an ambu- lance arrives. WAST should review the planning for the recruitment and retention of Com- munity First Responders. (4) The population of many rural and remote areas of North West Wale increases signifi- cantly during the months of July and August. WAST currently do not provide increased re- sources during these two months to cope with this increase in population. WAST should review their planning for effective allocation of resources to ensure the safety of this popula- tion during the months of July and August. 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 March 2016 . |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timeta- ble 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 In rsons icf Executive Betsi Cadwaladr University Health Board, Solicitors fo Lt co Ministry of Defence[and to the LOCAL SAFEGUARDING BOARD. | have also sent a copy ‘o the Chief Executive of Abertawe and Bro Morganwg Health Board as host for EMERTS and Chief Executive for Wales Air Ambulance. | 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 15 January 2046 Signature Assistant Coroner for North West Wales 37 Castle Square, Caernarfon, Gwynedd, LLS5 2NN Tel 01286 672804 | Fax 01286 675217
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.
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Mark Drakeford AC / AM %, FE, Y Gweinidog lechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services aN Llywodraeth Cymru Cymru Welsh Government Ein cyf/Our ref: Dr Nicola Jones Assistant Coroner North West Wales Pritchard Jones Evans Lane 37 Castle Square Caernarfon Gwynedd LL55 2NN A March 2016 Thank you for the regulation 28 report following the investigation into the death of Miss Jasmine Ruby Lapsley. This incident was reported to the Welsh Government by the Welsh Ambulance Services NHS Trust as a serious incident in line with our guidance. The Welsh Ambulance Services NHS Trust has submitted its investigation report and we are assured that a comprehensive investigation has taken place. In addition, my officials have been in touch with Betsi Cadwaladr University Health Board to confirm that appropriate actions have been taken in response to your report. The Welsh Ambulance Services NHS Trust and Welsh Air Ambulance chief executives and the chief ambulance commissioner are working together to ensure appropriate ambulance cover during night-time and busy summer periods. The Welsh Air Ambulance is expanding by an additional helicopter in July 2016 and funding has been made available for it to purchase and additional three helicopters in early 2017. Following a review of the Welsh Ambulance Services NHS Trust’s community first responders leadership arrangements, the use of hand-held devices has been successfully piloted to improve communications and the trust is engaging with community first responders to establish coordination of resources. The trust is also working with Search and Rescue and the UK Maritime Coastguard Agency to agree formal working arrangements. Welsh Government officials hold the Chief Ambulance Services Commissioner and the Welsh Ambulance Services NHS Trust to account through regular quality and delivery- focused meetings. We will endeavour to seek assurance the recommendations in your report are being actioned through these mechanisms. Bae Caerdydd « Cardiff Bay English Enquiry Line 0300 0603300 Caerdydd + Cardiff Llinetl Ymholiadau Cymraeg 0300 0604400 CF99 1NA Correspondence.Mark.Drakeford @wales.gsi.gov.uk Wedi’i argraffu ar bapur wedi’i ailgylchu (100%) Printed on 100% recycled paper | hope you find this information helpful. Jaucs ANON ; Merk Oeritrd Mark Drakeford AC / AM Y Gweinidog lechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services
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