Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0133, written 24 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 | 24 Apr 2017 |
|---|---|
| Reference | 2017-0133 |
| Deceased | Barry Hodges |
| Coroner | Sarah Slater |
| Coroner area | South Yorkshire (East) |
| Category | Community health care and emergency services related deaths |
| Organisation named | Yorkshire 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.
Mrs Sarah Louise Slater Assistant Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Yorkshire Ambulance Service Nhs Foundation Trust Trust Headquarters, Springhill Brindley Way, Wakefield 41 Business Park Wakefield WF2 0XQ CORONER | am Mrs Sarah Louise Slater, Assistant Coroner for South Yorkshire (East District) 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://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 01/09/2016 | commenced an investigation into the death of Barry Stuart Hodges, 69 . The investigation concluded at the end of the inquest on 20 April 2017. The conclusion of the inquest was a narrative conclusion. On the 23rd August 2016, Mr Hodges collapsed at Doncaster Tennis Club. An ambulance was called and coded Amber with a 19 minute response time but did not attend until 41 minutes after the initial call was made. On arrival, the paramedics found Mr Hodges to be in cardiac arrest, he was assessed and transferred to Doncaster Royal Infirmary where he was pronounced deceased. It is not possible to ascertain if the outcome would have been different if the ambulance had arrived sooner, although with a cardiac arrest any delay in treatment leads to a poorer prognosis. CIRCUMSTANCES OF THE DEATH Mr Hodges appeared to be a fit 69 year old man who regularly played tennis. On the 23 August 2016 Mr Hodges complained of chest pains and collapsed at the Tennis Club. An ambulance was called at 19:12 hours and there were two resources available at this time. These were not allocated due to the incident being uncoded. At 19:14 hours, Mr Hodges was coded amber with a response time of 19 minutes, but the despatcher did not review the resources available at the time of coding or within 2 minutes as set down in the protocol. No resources were allocated but potentially two were available. The protocol also states that a review of resources should take place every 10 minutes following coding but this did not occur. The first review of resources occurred at 19:28 hours when a resource was available but not allocated, and again at 19:35 hours when a resource was available but again not allocated. Mr Hodges’ condition deteriorated and a second call was made to Yorkshire Ambulance Service at 19:46 hours. At 19:47 hours, Mr Hodges was recoded as red and resources were allocated arriving at the scene at 19:53 hours. Bystander CPR was taking place when paramedics arrived at 19:53 hours. Mr Hodges was transferred to Doncaster Royal Infirmary but he was declared deceased a short time after arrival. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 The cause of death is:- 1a) Left ventricular failure; 1b) Ischaemic heart disease; 1c) Coronary artery atheroma. 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) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net” should an individual operative not manually refresh and look at the system. (2) A lack of knowledge/training/understanding of the protocols that 4 resources were available at different times but none were utilised. (3) Time scales were breached without further action ie. escalation to Senior Management, Clinicians or allocation of resources. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Chief Executive 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 49" June /2017. |, 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 ve sent a copy of my report to the hief Coroner and to the following Interested Persons || re and | | 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 24 April 2017 Signature Assistant Coroner for South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
PRIVATE & CONFIDENTIAL Mrs S.L Slater Assistant Coroner for South Yorkshire (East District) Coroners Court and Office Crown Court College Road Doncaster DN1 3HS Date: 9 June 2017 Dear Mrs Slater, Inquest touching the death of Barry Hodges Yorkshire Ambulance Service INHS| NHS Trust Legal Services Department Ambulance Headquarters Springhill Brindley Way Wakefield 41 Business Park Wakefield WF2 0XQ Tel: 01924 584 029 E-mail: coroners@yas.nhs.uk www.yas.nhs.uk Response to Regulation 28 Report to Prevent Future Deaths dated 24 April 2017 Thank you for your report dated 24 April 2017, issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The purpose of this letter is to provide you with a full response to the concerns set out in your report, in so far as these are issues which can be addressed by the Trust at this stage. 1) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net" should an individual operative not manually refresh and look at the system. ABoy, POS; Ny Cia 0, MINDFUL fare Ws sare Oy 2 ~— There is now a process in place within Emergency Operations Centre (EOC) whereby a “Call Alert” is highlighted on the Dispatcher’s, Team Leader's and Duty Manager's computer automated dispatch (CAD) screen. This alert highlights when an incident has not been allocated. We are also in the process of identifying the possibility of a system change to identify when a resource check has not been completed within the target timeframe. The introduction of these systems enables the direct managers of the Dispatchers to be made aware of any live incidents that have not been allocated a resource during the incident. Also the timeframes for resourcing of incidents for amber category calls has been reduced to 5 minutes from the original 10 minutes, this new time target has been communicated to all staff in the EOC. Further awareness on the importance of reviewing available resources will be emphasized to all staff at the EOC training away days throughout June and July 2017. We have also further introduced a systems change to assist the EOC management teams with identifying details that have not had a resource allocated within time scales. The system now shows a “minus minute” indicator on the Dispatcher’s, Team Leader’s and Duty Manager’s CAD screen which indicates for each incident how many minutes have passed without a resource being allocated. This enables the Team Leader or Duty Manager the ability to monitor all incidents to ensure they are compliant with timescales. The Trust is in the process of introducing revised colour coding of calls — the Trust will in the future be changing the amber category to red to ensure visually these calls are prioritized appropriately. Evidence based previous experience and working nationally with the Association Ambulance Chief Executives (AACE) that Red category calls create an increased awareness against other colours. We are also reducing the expected time to allocation for amber details (soon to be Red) from 2 minutes to 30 seconds once coding is confirmed or the detail is available for dispatch from the waiting stack. This change will assist in responding to these patients sooner and reduce any delays at the beginning of the dispatch process. The new process will be discussed, shared and educated on the EOC training away days with all staff and will also be visible on all dispatch bays in the updated Dispatch Quick Reference Guide. A lack of knowledge/training/understanding of the protocols that 4 resources were available at different times but none were utilised. MINDFUL 3 EMPLOYER *. swe 3) The Trust has intense training away days for all EOC staff set up to take place throughout the summer months. Part of these training away days will include reiterating to all EOC staff the core elements of their role, especially around the fundamental aspects of review, revise and allocate with emphasis on not delaying allocation to high priority calls. The attached (Appendix 1) Operational Alert was produced on 24 April this year to further reiterate to staff the need to allocate the most appropriate resource available without delay. EOC staff members have monthly 1:1’s at which the Trust are now able to produce personal performance information, this enables the manager to review whether the dispatcher is meeting appropriate targets, this includes information regarding resourcing of incidents. If it is found there are areas which require improvement the Trust allocates a team champion to sit with the staff member to supervise their work until it is felt that the staff member is performing satisfactorily. We are also in the process of introducing a Standard Operating Procedure (SOP) to ensure that Emergency Operations Centre Dispatchers are delivering consistently good standards of care to the patients of Yorkshire, this is attached (Appendix 2). This process will facilitate a fair and appropriate audit of incidents in the live environment to ensure that Dispatchers are supported in their role and areas of concern are addressed immediately where possible. All dispatch staff can be put through a Practice Developer Referral (PDR) for training and support to make sure relevant competencies meet the standard required. Time scales were breached without further action ie. escalation to Senior Management, Clinicians or allocation of resources. Performance frameworks have been introduced to audit individual staff members to improve the quality of the service provided on an individual basis. As a Trust all category 1, 2 and 3 (Purple, Amber, Yellow) delayed response incidents are reviewed by the clinical hub and reported on the Trust’s incident reporting system, Datix, this enables an incident to be declared and investigated if required. All patient harms are recorded to ensure an investigation is commenced should this be required. MINDFUL EMPLOYER Rae A PU OAS & < sae The Trust reviews all purple calls of 10 minutes and above delayed responses, along with all amber calls of 30 minute and above delayed responses and all yellow calls of 120 minutes and above delayed responses. This audit ensures the Trust monitors the reasoning behind delayed responses and learns lessons from them quickly. To assist with patient safety in relation to excessive and delayed responses, staff have been reminded of the reporting process and also reminded of an amendment to the definitions of delayed responses. Dispatchers are to follow the Dispatch Escalation and Excessive Timeframes guidance which can be found on the back page of the Dispatch Quick Reference Manual and also in the Dispatcher SOP. | hope the above response is satisfactory, please do not hesitate to contact me should clarification be required. Yours faithfully _ Rod Barnes Chief Executive Officer Yorkshire Ambulance Service NHS Trust MINDFUL 3 e/07< = Of0/s sfinarns BW AB’
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