Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0241, written 4 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Sep 2017 |
|---|---|
| Reference | 2017-0241 |
| Deceased | Anthony McCormack |
| Coroner | Fiona Borrill |
| Coroner area | Manchester City |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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: Emirates via DLA Piper Solicitors Secretary of State for Health, Department of Health Copied for interest to: Chief Coroner Family of deceased Manchester Airport Group North West Ambulance Service 1 CORONER I am Fiona Borrill, H.M. Area Coroner for the area of Manchester City. 2 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. 3 INQUEST The deceased, Anthony William McCormack, DOB 080/3/1959, who died on 02/06/2015 at Wythenshawe Hospital. I dealt with the inquest into his death on 04/07/16, 11 and 12/04/2017 and 05/05/2017. I recorded the pathological cause of death as: 1a Myocardial ischaemia 1b Coronary artery atherosclerosis 4 CIRCUMSTANCES OF THE DEATH On 02/06/2016 the Deceased boarded Emirates Airlines Flight EK020 at Manchester Airport, destination Dubai, and was seated at 47C. Whilst the aeroplane was taxing along the runway prior to take off, the Deceased became unwell and collapsed in his seat at 21.17hrs. He was assisted by airline staff and was transferred to the galley area for ongoing assessment and management, having communicated prior to transfer that he wished to vomit. He was initially treated as a fainting passenger He was placed in the recovery position, given oxygen and his breathing monitored. The Deceased was groaning and making noisy random sounds indicating abnormal breathing and his condition deteriorated rapidly on arrival to the galley. At 21.27hrs the Captain was alerted to the ongoing medical incident and the aeroplane taxied back to the stand arriving at 21.32hrs. The Tempus device, which monitors and record vital signs, indicated that for a period of 6 minutes and 23 seconds, from 21.25:26, blood pressure and pulse parameters were engaged. 1 North West Ambulance Service had been alerted to the incident and a sole paramedic attended the scene at 21.35 hrs The Deceased was lying on the floor in the recovery position and he noted that the Deceased was unconscious with no sign of breathing or palpable pulse. An AED was already attached to the deceased advising no shockable rhythm. No bystander Cardio Pulmonary Resuscitation (CPR) was being administered. The paramedic carried out Basic Life Support and following the arrival of colleagues from the Manchester Airport Fire Service and NWAS, Advanced Life Support was commenced. The Deceased was transferred by ambulance to Wythenshawe Hospital remaining in asystole throughout. Further Advanced Life Support was carried out at Wythenshawe Hospital. Resuscitation ceased and death was confirmed at 22.50hrs. At the end of the inquest I returned a Narrative Conclusion namely that the deceased died of natural cause; however, the rapid deterioration into cardiac arrest and the consequent seriousness of his condition was not fully recognised and CPR not commenced promptly prior to the arrival of the first paramedic. On the evidence earlier institution of CPR would not have prevented the deceased’s death. 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: Emirates Airline : The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR The adequacy and effectiveness of the procedures followed by Emirates staff in the event that the Tempus system is unable to provide assistance which was the case here. Department of Health I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources in November 2015 (for provision of more ambulances and recruitment of an additional 400 staff) I was also informed since April 2017 none of the nationally set targets have been met by any ambulance trust in England and Wales namely, a Red 1 response within 8 minutes 75% of the time, Red 2 within 19 minutes 95% of the time, I was also informed that there has been a massive increase of calls to 999 with consequent impact on response times and delays in ambulance turnaround at hospitals. 2 Consequent on the above and in this specific case there was only one paramedic on duty at any one time for the whole of Manchester Airport. Such paramedic being required to carry out Basic Life Support alone and unable to start Advanced Life Support. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 Tuesday 7 November 2017. 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 Chief Coroner and to Interested Persons. I have also sent it to organisations who may find it useful or of interest. 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 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. 9 Monday 4 September 2017. Ms Fiona Borril, HM Area Coroner, Manchester City Area 3
2 responses 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.
2 A Philip Dunne MP PREP Minister of State for Health Department of Health ° ichmond House Our reference: PFD-1097064 79 Whitehall London SW1A 2NS Ms Fiona Borril HM Area Coroner Manchester City Area HM Coroner’s Office PO Box 532 2A Manchester Town Hall 5 [z l] V E i Albert Square _ M60 2LA 3 NOV 2017 Tel: 020 7210 4850 Thank you for your letter of 4 September to the Secretary of State about the death of Mr Anthony William McCormack. I have been asked to respond. I was very saddened to read of the circumstances surrounding Mr McCormack’s death. Please pass my condolences to his family and loved ones. I appreciate this must be a very difficult time for them. : Your Report raises concerns about the level of paramedic cover at the Manchester International Airport. I should explain that the provision of emergency ambulance services is a matter for the local NHS. My officials have made enquiries with the North West Ambulance Service NHS Trust and the NHS Blackpool Clinical Commissioning Group (CCG), as lead commissioner for ambulance services in the North West region. I am advised that paramedic cover at the Manchester International Airport is by commercial arrangement with the Airport which funds the service. I understand that there is no obligation on the Manchester International Airport to provide anything more than first aid. However, I am informed that the North West Ambulance Service has provided Manchester International Airport with a paramedic service since 2008. I am advised that staffing comprises five solo paramedics working across a shift pattern resulting in one paramedic being on duty at all times, 24/7. The paramedics work closely with the Airport and receive special training, including airfield driving. Manchester Airport paramedics are required to have high levels of security and regular accreditation which means that in an emergency they are permitted through security checks without delay and unescorted. This is not the case for any other North West Ambulance Service personnel from outside the Airport, who are required to enter security checks and be escorted during their time airside. The site is exceptionally secure for obvious reasons and I am advised that the permissions they have alleviate previous issues of delays to patients. Activation to incidents is initiated by direct contact between the Airport operations/communications centre and the Manchester Airport paramedic. The paramedic will speak directly to the caller and make a judgement on attendance. When it is identified that an outside resource is required, the paramedic will contact the North West Ambulance Service by radio and request the back-up they require. In cases of cardiac arrest, this would be done immediately and would also include a call to the Manchester Airport communications centre for an “AED Call”. This results in the mobilisation of the Manchester Airport Fire Service to assist. While this is a great asset, it should be noted that there are strict regulations in place from the Civil Aviation Authority about response from the Fire Service to an airport incident. The Fire Service has seconds to respond to a fire and has to ensure that cover is not compromised by responding to other incidents. Within these considerations, I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels. In the case of Mr McCormack, I am advised that the incident was not ‘called in’ as a cardiac arrest. This status was only confirmed on the Manchester Airport paramedic’s arrival at the scene. The North West Ambulance Services advises that a review of 2016 cardiac arrest data for Manchester Airport shows a survival to discharge rate of 43.75 per cent, which is favourable compared to the national average of 25.6 percent. In addition, Return of Spontaneous Circulation (ROSC) rates are good, at 62.5 per cent, compared to the 50 per cent national average. Finally, as you will know, Manchester Airport is expanding. I am advised that work is underway to understand the impact this will have on the North West Ambulance Service and whether or not a second paramedic at Manchester Airport is required. This will be reviewed as the expansion takes place, but I am advised by Department of Health the North West Ambulance Service and its commissioners that they are satisfied a sole paramedic is adequate for the current activity (an average of 9.3 incidents a day in 2017). I note the comments in your Report about evidence heard at inquest around ambulance performance. I would like to take this opportunity to highlight that, following an independent evaluation of extensive trials, we have agreed NHS England’s recommendation to implement an improved ambulance performance framework, which: e Prioritises responses to the sickest patients, while helping reduce long waits for ambulance responses; e Ensures patients receive the response they need, first time; e Brings all patients under a national response standard; and Improves the efficiency and resiliency of the ambulance service in the face of rising demand. The NHS is now implementing these changes so that patients across the country can benefit from them. North West Ambulance Service has already transitioned to this framework. The Department continues to work closely with NHS England and NHS Improvement to monitor and support performance in 2017-18, and there is a range of ambulance improvement programme work underway. This includes work to improve the clinical capability and conditions for paramedics; commissioning and operating models for ambulance services; and ambulance trust productivity and efficiency. I hope this information is helpful. Thank you for bringing the circumstances of Mr McCormack’s death to our attention. on (UY Domne PHILIP DUNNE
af Emirates 5 November 2017 H.M. Area Coroner Manchester City Area PO Box 532 Manchester Town Hall Albert Square Manchester M60 2LA UNITED KINGDOM Dear Ma'am Inquest Touching the death of Mr Anthony McCormack Regulation 28: Report to Prevent Future Deaths Further to the above dated 4 September 2017, we provide our responses to the two matters of your concern below. 1. “The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR.” First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue. We also note that it is widely recognised by experts in the field of resuscitation that recognition of agonal breathing is extremely problematic even for seasoned medical professionals and is not always present in all cases of cardiac arrest. Emirates also closely monitors the latest research and developments in pre-hospital emergency care and resuscitation on an ongoing basis. As and when any of the recognised international resuscitation bodies report improved methodologies in handling medical emergencies, Emirates promptly assimilates these improved procedures into its crew medical training programs to ensure that any on-board medical emergency is handled by our crew to the highest possible standard of modern medicine. As such, we will continue to follow this approach and do not propose to take additional action above and beyond that which is detailed above. 2. “The adequacy and effectiveness of the procedures followed by Emirates staff in the event that the Tempus system is unable to provide assistance which was the case here.” P.O. Box 686, Dubai, United Arab Emirates, daniel aaycl blob epya WI s.ya Tel: +971 4 708 1111 +4VV E V-A MM craila emirates.com emirates.com a SH Emirates Emirates has robust procedures in place to deal with medical emergencies and all crew are trained in these procedures on an annual basis. The primary focus of these procedures is on practical, manual skills in assessing and providing care, which can be used by crew in a wide range of on- board medical emergency situations. For example, crew are trained to use the “Look, Listen and Feel” method, together with assessing the level of responsiveness, to determine the adequacy of breathing of a passenger in medical difficulty. The Tempus device or other on-board medical devices are only used as an adjunct to support the crew in the use of these primary assessment methods. These procedures have been designed and implemented in order to ensure that the crew are able to assess the medical condition of a passenger as quickly and accurately as possible, even where there are instances of communications or equipment errors. We do not propose to take additional actions for the above reasons. Yours faithfully ZAI For Emirates
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