Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0260, written 19 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2016 |
|---|---|
| Reference | 2016-0260 |
| Deceased | Patricia Mercieca |
| Coroner | Dr Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Community health care and emergency services related deaths |
| Organisation named | London Ambulance Service NHS Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Tunstall Response, Ascot House, Malton Way, Adwick le Street, Doncaster. DN6 7FE. 1 CORONER | am Dr Fiona Wilcox, Senior Coroner, for the coroner area of Inner West 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 On the 17" July 2015 an investigation was opened touching the death of Patricia Mercieca, who died aged 60 years on the 14" July 2015 at Flat 34, Charlwood House, Vauxhall Bridge Road, London. SW1V 2SY. The inquest was concluded on the 12th July 2016 at Westminster Coroner's Court. The following findings and determinations were made: The medical cause of death was recorded as: 1(a) Chronic Obstructive Pulmonary Disease and Asthma and Methadone Intoxication. How, when and where and in what circumstances the deceased came by her death: Patricia had a long standing history of drug dependence, severe COPD and asthma and was resident in assisted living accommodation. On the 14/7/2015 she pulled the emergency cord at her address at approximately 21:00 and informed the call handler that she could not breathe. She arrested shortly after this such that on the arrival of the LAS at approximately 22:15 she was found to be deceased. Conclusion of the Coroner as to the death: Natural Causes and Drug Dependence 4 | CIRCUMSTANCES OF THE DEATH Evidence taken at the inquest was that the call handler called the LAS to request an ambulance however did not give correct information to the LAS such that the call could be correctly prioritised. The LAS clearly on two occasions advised the call handler to recheck whether Ms Mercieca could talk without becoming short of breath which if she could not would have upgraded the call priority. The call handler did not do this. In fact when the call handler re contacted Ms Mercieca to let her know an ambulance was on the way, she did not respond to him at all. He did not pass this information onto the LAS, and also did not, in contravention of the agreement between Tunstall Response and Westminster, contact the manager of the supported housing in which Ms Mercieca was resident. The evidence was that if he had so done, that manager was at home in the same accommodation block and would have immediately attended Ms Mercieca’ s flat to give any appropriate assistance. On consideration of the evidence since it was not known when Ms Mercieca arrested, it could not be said on the balance of probabilities that had the call been appropriately handled she would have survived and so the failures could not be said to be causative in her death. The evidence was that the call handler was acting in line with company procedures when he did not follow up with Ms Mercieca as requested by the LAS. Further not all authorities with which Tunstall are contracted to respond to handle calls require that their managers are contacted when a resident contacts Tunstall in an emergency. | understand that Tunstall handle approximately two million calls per annum, of which approximately 10% are medical emergencies. Most authorities with which they contract do not have resident managers in their supported housing schemes. The evidence was also that the medical history of Ms Mercieca was not recorded on the computer screen available to the call handler and so could not be passed to the LAS. This information would have also upgraded the call. | understand that audit procedures are in place to address this matter. CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. — (1) That the call handlers need to be refresher trained in relation to contacting resident managers for Westminster residents following a medical emergency call. (2) That wherever there is a person contacting them in an emergency where there is a manager, that manager should be contacted whatever authority covers the person contacting the call handler. S (3) That if a call handler is directed by emergency services such as the LAS, or other relevant professionals such as a doctor to obtain further information or reassess then they should do so and pass any information so gained back to the agency or professional that requested it. (4) That call handlers be trained such that if they get no response when contacting a person who has contacted them and that person is a user of the emergency call system, then immediate concerns should be raised with the appropriate agencies for example the LAS and resident scheme manger. 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. It is for each addressee to identify the concerns relevant to their own areas of responsibility. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13" September 2016. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : c/o Edmund Conybeare, Legal Studio Solicitors, The Tannery, 91 Kirkland Road, Leeds. LS3 1HS. Operations Manager, Tunstall Response, Ascot House, Malton Way, Adwick le Street, Doncaster. DN6 7FE. = 5 woos a. Westminster City Council, Westminster City hall, 64, Victoria Street, London. SW1E 6QP. | have also sent a copy to the LAS: Head of Quality Assurance, London Ambulance Service, 220 Waterloo Road, London. SE1 8SD. | 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. 19" July 2016. Dr Fiona Wilcox, HM Senior Coroner, Inner West London, Westminster Coroner’s Court, 65, Horseferry Road, London. SW1P 2ED.
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.
London Ambulance Service NHS NHS Trust Executive Office Headquarters 220 Waterloo Road London SE1 8SD Tel: 020 7783 2000 Director Response and Customer Operations Tunstall Healthcare (UK) Ltd Ascot House Malton Way Adwicke le Street Doncaster / & DN6 7FE a Our ref : INQ/11406/15 2 December 2016 Response to Regulation 28 Report relating to Patricia Mercieca deceased | apologise for the delay in writing after receiving a copy of your letter dated 30 August 2016 from a. HM Senior Coroner on 27 September 2016, arising from the Regulation 28 Report issued by Dr Wilcox after the inquest into the death of Patricia Mercieca. Whilst supporting whole heartedly your wish to ensure that appropriate lessons are learned which may prevent future deaths | should like to respond to your invitation to the Coroner to consider: “What steps could be taken by an emergency service when triaging calls where it is informed that a third party requesting an emergency response is not in attendance with the casualty. Tunstall feel that the London Ambulance Service ‘script’ failed to fully recognise this situation in the present case resulted in additional confusion between the respective call operators.” My understanding of the London Ambulance Service NHS Trust’s call records concerning the call made on behalf of Ms Mercieca was that : a single call was made, it was known and recorded that it was a third party caller who was not with the patient. Regrettably when contact with Ms Mercieca was lost and Tunstall were unable to make contact again they did not update the LAS of that situation. Had Tunstall informed the LAS that communication had been lost and Ms Mercieca was not responding, | am advised py Head of Quality Assurance Control Services, who gave evidence at Ms Mercieca’s inquest, that the call would have been upgraded to a Category A or Red call with a target response of 8 minutes for 75% Red calls . As HE <xplainea in her evidence while the call was being held awaiting an available response it was reviewed by an LAS clinician with the intention of making a clinical assessment by telephone, but without a contact telephone number the clinician upgraded the priority of the call from C2 to C1. | am satisfied that there are no changes to the questions asked of 999 callers that would have enabled the LAS to triage the call differently aside from the update that contact with the patient had been lost and she was not responding. | am hopeful however, that the measures taken by Tunstall to address the Coroner’s concerns will help prevent future deaths. If you would find it helpful to meet and discuss further with EEeand our Deputy Director of Operations, Control Services please let my EEE know so that the arrangements can be made. Yours sincerely cc: Dr Fiona Wilcox , HM Senior Coroner, Westminster Coroner’s Court .~ Page 2 of 2
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