Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0132, written 21 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2017 |
|---|---|
| Reference | 2017-0132 |
| Deceased | Najeeb Katende |
| Coroner | Edwin Buckett |
| Coroner area | Inner North London |
| Category | Community health care and emergency services related deaths · Child Death (from 2015) |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Najeeb Katende (died 10.10.2016)
THIS REPORT IS BEING SENT TO:
Mr Andrew Grimshaw
Chief Executive
London Ambulance Service NHS Trust
220 Waterloo Road
London SE1 8SD
1
CORONER
I am: Edwin Buckett Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
Following the death of Master Najeeb Katende, aged 15 years, on the
10th October, 2016 an investigation into his death was carried out which
concluded at the end of the inquest on 10th April, 2017. I made a narrative
determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
At about 10am on the 10th October, 2016 Najeeb collapsed at school. A
paramedic from LAS attended and was with Najeeb by about 10.12am.
The paramedic considered that Najeeb was in cardiac arrest and used at
LP15 defibrillator on him in manual mode. He interpreted the readings
from that device as showing that Najeeb had a non-shockable heart
rhythm and did not defibrillate him.
At about 10.36am, a subsequent heart rhythm check was carried out by
1
an Advanced Paramedic (who had by then attended the scene) which
showed that Najeeb had, in fact, a shockable rhythm. He was then
defibrillated 6 times but was pronounced dead at 11.46am at hospital.
The data from the LP 15 device was downloaded and analysed. It
showed that Najeeb had a shockable rhythm when first tested at
10.12am.
Accordingly, Najeeb was not defibrillated for a period of about 24 minutes
between 10.12am – 10.36am.
The medical cause of death was found to be Sudden Cardiac Death
Syndrome.
I found that the delay in defibrillating Najeeb significantly reduced his
chances of survival although I did not find, on the balance of probabilities
that he would have survived had this been done earlier.
5
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.
1. Evidence was given by
(Consultant Paramedic) that:
Based on LAS statistics the survival rate from cardiac arrest,
is around 31% when
is a shockable rhythm
where
there
defibrillation occurs;
This is to be contrasted against a survival rate of around 9% for all
presenting rhythms;
For every minute of cardiac arrest where a shockable rhythm is
present and no defibrillation is carried out, survival decreases by
approximately 7-10%.
2. Evidence was also given from other Ambulance staff that:
Despite the presence of other staff between 10.12am and
10.36am, no cross check was made as to whether Najeeb had a
shockable rhythm;
If an Automated External Defibrillator, such as those used by
members of the public had been applied, this would have detected
a shockable rhythm and would have proceeded to defibrillate
Najeeb.
3. I consider that it would be of great benefit if LAS were to take the
2
following steps, namely training and instruction to staff to:
Actively cross check with another clinician whether a shockable
rhythm is present when attending an incident of this sort;
Use the defibrillator in AED mode when first attending as a matter
of routine, or at the very least if uncertain when interpreting a
heart rhythm;
Further educate on the interpretation of shockable rhythms from
readings provided by defibrillator devices.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 17th June, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England and Wales;
QAM, Chairman of Association of Ambulance
Chief Executives
I 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
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.
it useful or of
find
9
DATE 21st April, 2017 SIGNED BY
ASSISTANT CORONER EDWIN BUCKETT
3
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