Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0323, written 30 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 | 30 Aug 2016 |
|---|---|
| Reference | 2016-0323 |
| Deceased | Harry Gill |
| Coroner | Michael Singleton |
| Coroner area | Blackburn, Hyndburn and Ribble Valley |
| Category | Community health care and emergency services related deaths |
| Organisation named | North West 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer NHS Digital 1 Trevelyan Square Boar Lane Leeds LS1 6AE CORONER Tam Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. CORONER'S LEGAL POWERS I 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. INVESTIGATION and INQUEST On the 6"" day of June 2016 I commenced an investigation into the death of Harry Stuart Gill aged 72 years. The investigation concluded at the end of the Inquest which was concluded on the 24 day of August 2016. The conclusion of the Inquest was that Harry Gill died from a heart attack brought on by the effects of vomiting caused by an intermittent blockage in his bowel. His death could probably have been prevented but for the failure to appropriately assess his medical condition. CIRCUMSTANCES OF THE DEATH Harry Gill became unwell and started to vomit on Saturday 28 May 2016. He was. unable to tolerate food and was trying to take regular sips of water. At 09:56hrs on Wednesday 1° June 2016 Mrs Gill on behalf of her husband contacted NHS 111. The health advisor triaged the call using the vomiting pathway which should have led to a Green 2 response but was incorrectly processed. Arrangements were however made for a clinician to call back some two hours later. The clinician should have reached a Green 2 response but the triage was incorrectly processed. That call was concluded with advice that should the symptoms get worse or the condition change to ring back NHS 111. At 18:28hrs on Thursday 2" June 2016 a further call was made to NHS 111 at which time the health assistant incorrectly processed the call and although a Green 2 response should have been reached instead arrangements were made for a clinical advisor to call back. Three and a half hours fater at 21:55hrs. That call was correctly processed and that call concluded with the clinician indicating that an ambulance was going to be arranged. At 22:2ihrs on the 24 June 2016 a nurse from the Urgent Care Desk then telephoned Mr Gill indicating that the ambulance was not now be being dispatched and that | arrangements were going to be made to try and contact and out of hours doctor. Mr Gill collapsed and died shortly thereafter. The conclusion reached by who is the 111 Clinical Quality and Nurse Lead for the NHS 111 . Service of the North West Ambulance Service NHS Trust concluded that of the five i calls only one was processed correctly. [I concluded “we have identified that throughout the calls made to NHS 111 and UCD questions stems around vomiting blood/coffee ground vomit were poor. There was not much evidence of supporting information being used even though this is available within the pathways and the Manchester Triage question. Assumptions were made that the caller/patient understood the presentation of blood in vomit (ranging from bright red to dark brown or black). There was not much probing around the patient | vomiting brown fluid or smelling of “poo”. Since this incident we have requested a change to the vomiting and/or nausea pathway via NHS Pathways Issue log, in particular the question stem relating to vomiting blood or faeces. The question stem is misleading to health assistants in regard to having three parts. As yet we have had no response from NHS Pathways regarding this change. CORONER'S CONCERNS 5 During the course of the Inquest the evidence revealed matters giving arise to concern. In my opinion there is a risk that further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTERS OF CONCERN being as follows: - That on four out of five telephone conversations between Mr Gill and his wife and NHS 111 only one call elicited the appropriate response. It would therefore appear that the vomiting pathways is not sufficiently robust to ensure an appropriate response. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 31% October 2016. I, the Coroner, may extend this 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 Chief Coroner and to the following interested person, namely: | EER North West Ambulance Service I am also under a duty to send the Chief Coroner a copy of your response. 2 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. Signed by: ...... 30 August 2016 H M Senior Coroner for Blackburn, Hyndburn & Ribble Valley
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.
NHS Digital 1 Trevelyan Square Boar Lane Leeds LS1 64E HM Senior Coroner for Blackburn, Hyndburn and Ribble Valley Coroner's Office Enterprise Centre Furthergate Blackburn BB1 3HQ 11 October 2016 Dear Mr Singleton | am writing in response to a Section 28 ruling from HM Senior Coroner. This follows the tragic death of Harry Gill who passed away on the 2nd June 2016. This was followed by an investigation and inquest which concluded on 24/8/2016. | am writing in my role as the Clinical Director for NHS Pathways which is the clinical triage platform for the national NHS 111 service. | amMEB, BA, MSc, MB ChB (Sheffield). The Coroner has requested that NHS Pathways review its management of the vomiting pathways and report on any improvements that have been made. To aid this process NHS Pathways entered into discussions with the Clinical and Quality Lead for the North Western Ambulance Service (NWAS) to better understand their concerns regarding the structure of the vomiting questions. We agreed there was scope to enhance our content and commenced a review with our clinical team. This review has now concluded and [ can report the following changes to the vomiting questions with rationale. CURRENT QUESTION The current question presented to the call handler and then asked of the patient is; ‘Have you vomited blood or faeces?" Call handlers at NWAS reported a degree of confusion with the question and not enough supporting information if the patient answered positively. At present call handlers may ask the question as it appears without making full use of existing supporting information to probe directly about coffee ground vomiting, and a caller may not realise that coffee ground vomit is blood Information and technology www.digital.nhs.uk for better health and care enquiries@nhsdigital.nhs.uk Digital PROPOSED CHANGES We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate a localised gastric bleed. The question that will be asked in the next release of the algorithms will be; Have you vomited any of the following? A1- Coffee ground vomit Supporting information presented to the call handler; This means the individual has brought up or vomited dark brown or black material that looks like soil or coffee-grounds. Blood that has been in the stomach often looks like this. A2-Blood Supporting information presented to the call handler; This means any blood visible in vomit. This also means any blood in or near the mouth. The blood may have been forcefully vomited up or just be oozing or welling from the mouth. A3- Faeces Supporting information presented to the call handler; This means vomit that looks and smells strongly of faeces (poo). This work has been concluded and will be issued to all NHS Pathways sites for the next release in the spring of next year. In addition we have further enhanced our site training package for the management of vomiting in recognition of the difficulties in identifying the nature of vomit remotely via third party telephone triage. | am happy to answer any further enquiries from HM Coroner. Yours sincerely Clinical Director NHS Pathways
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