Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0307, written 26 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Aug 2016 |
|---|---|
| Reference | 2016-0307 |
| Deceased | Kyles Lowes |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Northumbria Healthcare NHS Foundation 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.
Tony Brown LLM H M Senior Coroner 17 Church Street Berwick-upon-Tweed North Northumberland TD15 1EE Tel: 01289 304318 Fax: 01289 303591 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Yvonne Ormston Chief Executive NEAS NHS Foundation Trust Bernicia House, The Waterfront Goldcrest Way, Newburn Riverside Newcastle-upon-Tyne, NE15 8NY Chief Clinical Officer NHS Northumberland Clinical Commissioning Group County Hall, Morpeth, NE61 2EF 1 | CORONER | am Tony Brown, senior coroner, for the coroner area of North Northumberland 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 30" January 2015 | commenced an investigation into the death of Kyle William Lowes aged 16 years. The investigation concluded at the end of the Inquest on 17" August 2016 with the following narrative conclusion:- ‘Kyle William Lowes was riding his motor scooter at North Road, Berwick-upon-Tweed at approximately 10.00 p.m. on 30.01.15 when his motor scooter collided with a Vauxhall Astra motor vehicle being driven directly across Kyle's path when turning right from the opposing carriageway. Emergency services were contacted at 10.02 p.m. by a witness to the collision. An ambulance crew was not called by ambulance control from the nearby Berwick ambulance station because they had been stood down for their meal break at 10.00 p.m. An alternative paramedic was directed from Wooler who attended at 10.28 p.m., followed very shortly after by the Berwick crew who had on request from the Wooler paramedic, agreed to come off their meal break. Despite determined attempts at resuscitation Kyle could not be revived and his death was pronounced at 10.56 p.m. by paramedic | The Forensic Pathologist | found that the medical cause of Kyle’s death was due to a blunt head injury and gave his view as Pathologist though not as a Practising Specialist who treats patients, that the severity of Kyle's injuries and the distance from a major trauma hospital meant that it was unlikely that the fatal outcome for Kyle would have been any different had the paramedics been able to arrive sooner. CIRCUMSTANCES OF THE DEATH The incident was reported to North East Ambulance Emergency Control Centre at 10.00 p.m. on 30.01.15. Two minutes earlier the Berwick paramedic team day shift had gone off duty because there are only two ambulance crews provided between 10.00 a.m. and 10.00 p.m. and one overnight crew operating ‘mid shift’ between 6.30 p.m. and 6.30 a.m. who were instructed to take their statutory meal break. They could not therefore be contacted by ambulance control. This resulted in a travelling time of 26 minutes to the incident from the nearest paramedic resource (Wooler) instead of 3 minutes from Berwick-upon-Tweed. The practical difficulties encountered with Kyle Lowes’ emergency attendance were that Kyle required urgent advanced life support for the restoration of his breathing and a period of 26 minutes while waiting for a first responder from Wooler might have affected his chances of survival. 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. — The new Northumbria Specialist Emergency Care Hospital now make better provision for the County of Northumberland as a whole, but extends still further the long journey times for emergency care from Berwick-upon-Tweed, a sizeable border town, with a population which trebles throughout the tourist season because of its location as a holiday destination. By having only one paramedic crew after 10.00 p.m., if that crew is on a meal break, or as they regularly need to do, attend duties in another part of the County, risk is created to the population of Berwick-upon-Tweed by significant delays in attending life threatening incidents after 10.00 p.m., as there was in Kyle’s case. | was informed at the Inquest that NEAS are introducing a scheme whereby paramedic crews will be asked at the start of each shift whether they are willing to be contacted for emergency calls during their meal breaks, which might go some way towards helping to resolve the concerns but does not provide any certainty while resting only on the goodwill and agreement of ambulance personnel concerned. This proposal for response to emergency calls during meal breaks would also not address the risk of delayed response times when the single Berwick ambulance crew after 10.00 p.m. is called upon for duties out of the area. 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. At the Inquest | was informed that care would be provided in a different way in future, due to changes in NICE Guidelines but | remain concerned about the underlying question of service provision, and believe that you should take some action to address this. This report is addressed to North East Ambulance Service as an organisation having the power to take some action and to the Clinical Commissioning Group, because | was informed at the Inquest that the Group enable, commission or fund the provision of the services and NEAS stated in evidence that they are dependent upon services being commissioned by the Group. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28"" October 2016. |, 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:- EEE Direct Line Group and to Local Safeguarding Children Board. | have also sent it to Councillor Leader of Northumberland County Council, Anne Marie Trevelyan MP and Right Honourable Jeremy Hunt MP, who may find it useful or of interest. 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. DATE 26” August 2016 here TONY BROWN HM Senior Coroner for North Northumberland
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.
OFFICIAL SENSITIVE PERSONAL INHS| Northumberland Clinical Commissioning Group Private and Confidential County Hall Morpeth Northumberland Mr Tony Brown NERIGEE HM Senior Coroner for North Northumberland 17 Church Street Berwick upon Tweed Northumberland TD15 1EE 21 October 2016 Dear Mr Brown Inquest into the death of Kyle Lowes (Deceased) Regulation 28 Report to Prevent Future Deaths We write in response to your Regulation 28 Report to Prevent Future Deaths dated 26 August 2016, following the Inquest into the death of Kyle Lowes, which was held on 16 and 17 August 2016 at Berwick upon Tweed Coroner's Court. We were not invited to attend or provide you with evidence in respect of the commissioning of ambulance services, and would have valued the opportunity to provide this information to you and the family in advance of your decision to issue a Regulation 28 Report. You addressed the report to NHS Northumberland Clinical Commissioning Group (Northumberland CCG) because you were informed at the Inquest that we enable, commission or fund the provision of the services and that the North East Ambulance Service (NEAS) stated in evidence that they are dependent upon the services being commissioned. Northumberland CCG is currently one of four nominated lead CCGs who actively participate in commissioning and contracting of ambulance services on behalf of all 10 CCGs in the north east region. The four lead CCGs represent both rural and urban areas ensuring the challenges across these diverse geographies are discussed and population needs are considered when contracting for services. Through quality standards and continual performance management, commissioners work closely with NEAS to ensure the dynamic deployment of resources can be adapted to meet the changing demands on them as a service. We do not however dictate the operational decisions made as to the deployment of resources. Enabling NEAS the freedom to deploy resources across the county and the north east within the parameters of quality requirements ensures the provider, who is best placed to understand the demands, takes the most appropriate action when necessary. For example NEAS has stated that an additional rapid st ABO, SS = a & a A § 0407/8 c “ “] a Osage” OFFICIAL SENSITIVE PERSONAL response vehicle resource will be allocated to north Northumberland from 1 December 2016. This will be provided within current funds and will enhance the resource to this rural area and improve performance times to our rural population. Whilst some elements of ambulance activity are increasing, there has been a 2.1% decrease in total ambulance activity since 2013. The activity profile in Northumberland sees more requests from general practice and health care professionals and less red calls than other CCG areas, this relates to general practice and community services visiting more patients at home and providing services across the rural geography of the county. There has been an increase in the numbers of red life threatening calls for ambulances (category red 1 and 2), and commissioners have made a conscious decision to increase the overall expenditure on ambulance services and commit to supporting their transformation programme. The contract with NEAS is a block contract, offering financial stability for both provider and commissioners over a two year period whilst multiple initiatives and service transformation projects are progressed. The contract covers all emergency, urgent and planned patient transport as well as national contingency services such as the Hazardous Area Response Team, Medical Emergency Response Incident Team and encompasses the regional emergency planning and the National Intensive Care Bed Information Service. NEAS has reported an impact on their workforce and resources due to a shortage in emergency care paramedics. To mitigate this they have developed transformation projects to ensure the service can meet current and future demands but to also ensure patients can reach the appropriate care at the right time. These projects are supported by the CCGs and form part of the wider urgent and emergency care service developments across the north east. The transformation projects include: e Increased emergency care workforce planning. e Enhanced front line clinical management. e Utilising contract income to increase capacity to compensate for staff vacancies with third party resource. e Participation in the national ambulance response programme pilot. e Trial to use Fire and Rescue:services as first responders. e Increased clinical advice capacity within the call centre - Paramedic clinical hub. More locally Northumberland CCG has required NEAS to work closely with Northumbria Healthcare NHS Foundation Trust (NCHFT) to plan for the challenge of the new ways of working at the new Northumbria Specialist Emergency Care Hospital (NSECH) in Cramlington. In an attempt to mitigate the impact of the operational change to where patients access care, the CCG has sought assurance by specifying that: e Given the location of the county and its border with Scotland, NEAS developed protocols to ensure their crews remain in England and more specifically in Northumberland when clinically appropriate. OFFICIAL SENSITIVE PERSONAL e Continued joint working between NEAS and the Scottish Ambulance Service to provide vital cover if a NEAS resource isn’t available to respond to a life threatening call. e Regional agreement to a divert policy to ensure patients are transferred to the nearest hospital and ensure treatment is administered within appropriate time frames where there are known delays at some hospital A&E departments. Northumberland CCG recognises there is further action required to improve the ambulance handover processes at the NSECH and has commissioned the national Emergency Care Intensive Support Team (ECIST) to undertake a root cause analysis and improvement plan to address all issues. This work is due to commence in the coming weeks. The CCG has worked with all provider partners to establish the local A&E delivery Board, Chaired by the Chief Executive of NHCFT, which will oversee the outcomes from the ECIST input to ensure all providers in Northumberland do what is required to deliver safe and effective services to the population. This is a continuation of the system resilience network established over the previous two years. With the aim of addressing overall capacity, and to join up services, the CCG is working with NHCFT, NEAS, GP surgeries and community nursing services to review the services in Alnwick and Berwick to ensure all health care professionals are used appropriately. This means that providers share staff and their skills to treat patients most effectively and efficiently. This includes an agreement between NEAS and Northumberland CCG that, where needed, in order to fill significant gaps in service provision or to attend to life-threatening emergencies when there is no closer paramedic vehicle, community paramedics will be moved out of their designated area in order to assist. This will be on an exceptional basis, and the community paramedics will remain based within their local rural areas. This review aims to align with NEAS’ plans to introduce an Advanced Paramedic Practitioner supporting rural crews and avoiding unnecessary journeys to the NSECH but also building community base care and networks with local GPs, the hospitals services, community and out of hours providers. Northumberland CCG also welcomes the intention of NEAS to deploy an additional Rapid Response Paramedic in the north of the county, increasing the resource to respond to emergency calls, from December 2016. The CCG acknowledges the concerns of the coroner with regards to provision of services in rural areas across the north east including Berwick and north Northumberland and wish to stress that as commissioners it will ensure NEAS and all partner providers do all within their power recognising the issues discussed within this letter, to deliver a safe service to the population of rural Northumberland and across the north east as a whole. Yours sincerely le J \ikeve G a Chief Clinical Officer NHS Northumberland CCG
See every Prevention of Future Deaths report matching Northumbria Healthcare NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.