Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0401, written 17 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2017 |
|---|---|
| Reference | 2017-0401 |
| Deceased | Kathryn Richmond |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West Midlands Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Jeremy Hunt MP, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS 7 Chair of the Association of Ambulance Chief Executives, 32 Southwark Bridge Road, London SE1 9EU CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 21% April 2015, an investigation was commenced into the death of Kathryn Verina Richmond, born on the 28" March 2015. The investigation concluded at the end of the Inquest on the 8” November 2017. The Medical Cause of Death was: 1a Hypovolemic Shock 1b Spontaneous Ruptured Spleen 1c Infectious Mononucleosis Infection The conclusion of the Inquest was that Kathryn Verina Richmond died as a consequence of naturally occurring disease, where there was a delay in her receiving necessary lifesaving treatment. CIRCUMSTANCES OF THE DEATH On the 21st April 2015, the deceased, who had approximately 12 months previously suffered with glandular fever, collapsed at her home address at An ambulance was called immediately at 0.14 hours. South West Ambulance Service Trust (SWAST) initially categorised the call as a Red 2 call and an ambulance was dispatched at 0.15 hours. Due to insufficient probing on the call, by the end of the call it was downgraded to a Green 2 call and the ambulance was stood down at 0.21 hours. A further call was made to SWAST by the deceased's parents at 0.41 hours and the call was categorised as a Red 2 call and an ambulance was dispatched at 0.45 hours. A clinical review was then carried out with insufficient probing and the call was then downgraded to a Green 2 call and the ambulance dispatched was stood down at 0.57 hours. An ambulance arrived at the deceased's home address at 01.39 hours and she was taken to Poole Hospital, Poole where she arrived at 02.17 hours. She went into cardiac arrest and following resuscitation was taken to theatre and underwent a laparotomy which revealed a ruptured spleen. Despite receiving necessary lifesaving treatment her condition deteriorated and she died that morning. Between 0.00 hours and 02.00 hours on the 2ist April 2015 the demand for ambulances with SWAST was 29% higher than predicted, there were 14 ambulances running and at times up to 6 ambulances were on meal breaks at the same time and therefore unable to attend calls. NER’ ERN. 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. During the inquest evidence was heard that: i. At the time of Miss Richmond's death, the South West Ambulance Service Trust (SWAST) did not operate staggered shifts for their ambulance staff which meant that their meal time breaks to be taken in line with European Working Time Directives, fell at a similar time. The result of this was that the number of available ambulances running at certain times was significantly reduced. On the evening of Miss Richmond’s. death there were 14 ambulances running and for a period there were 6 ambulances on meal breaks at the same time meaning they were unable to attend calls. ii. SWAST undertook a trust wide rota review following Miss Richmond’s death which has resulted in the staggering of shifts for ambulance crew. This has resulted in the number of ambulances taking meal breaks at any one time being reduced and more resources being available to attend calls. This will reduce the delays in attending emergency calls and could therefore prevent future deaths. iii. Evidence was given that within England and Wales other Ambulance Service Trusts are still be operating on non-staggered shift patterns which means that there is a risk that resources are not being used as efficiently as they could be and that there could be unnecessary delays in crews attending emergency calls in those Trust areas. 2. Ihave concerns with regard to the following: i. Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts, there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time. I therefore request that a review is undertaken of the guidance given to Ambulance Service Trusts regarding the structuring of their rota system to stagger shifts which in turn will stagger meal breaks to ensure as many resources, as possible, are available at any one time. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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, 12" January 2018. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Leigh Day, Priory House, 25 St John’s Lane, London, on behalf of the family (2) Bevan Brittan LLP, Fleet Place House, 2 Fleet Place, London EC4M 7RF on behalf of SWAST 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. Dated Rachael C Griffi 17 November 2017
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.
Aor Steve Barclay MP Departm ent Minister of State of Health 39 Victoria St London Your reference: RCG/01473-2015/LJ SW1H OEU Our reference: PFD-1107336 Tel: 020 7210 4850 Ms Rachel C Griffin HM Senior Coroner, Dorset The Coroner’s Office R ECEIVED Town Hall 18 JAN 2018 Bournemouth — sf ee BH2 6DY 15 JAN 2018 Thank you for the Regulation 28 Report to prevent future deaths issued to the Secretary of State for Health and Social Care on 17 November 2017 following the inquest into the death of Miss Kathryn Verina Richmond. I am responding as Minister with responsibility for ambulances and I apologise for the slight delay in doing so. Firstly, I would like to say how extremely saddened I was to read of the circumstances surrounding Miss Richmond’s death. Please pass my condolences to her family and loved ones. The concerns highlighted in your report are around the staggering of shift patterns of ambulance crews to maximise resources and avoid delays in attending emergency calls where ambulance staff take meal breaks at the same time. You ask that a review is undertaken of guidance to ambulance trusts regarding rota systems and the staggering of shifts to ensure that as many resources as possible are available at any one time. Your report was issued to the Association of Ambulance Chief Executives (the AACE), which acts as a national co-ordinating voice on issues of policy and practice for ambulance trusts. My officials have liaised with the AACE to inform this response. I am aware that Mr Anthony Marsh, Chair of the AACE, responded to your report on 8 January. You will therefore know that the AACE provides a function that enables learning from serious incidents occurring within individual ambulance trusts to be shared nationally. This allows action to be taken where necessary across ambulance trusts within England to avoid similar incidents occurring. Learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care. I am advised that the AACE will ensure that the learning from this incident is shared nationally to allow other ambulance trusts to review their procedures and ensure their internal control room processes are adequate. I can confirm that the Department of Health and Social Care does not issue specific guidance to ambulance trusts on the structure of their rostering systems or meal break arrangements. Neither does the AACE have the power to mandate ambulance trusts to make changes to their operating practices. Paramedic meal breaks and shift pattern arrangements are operational matters for individual ambulance trusts. However, I am advised that all ambulance services are aware of the need to stagger meal breaks as much as possible and to regularly review rostering systems to stagger start and finish times and therefore meal breaks. In addition, all ambulance services have arrangements in place to enable clinicians to be interrupted during their breaks in the event of a major incident, and all services have additional arrangements for crews to be disturbed during a break on a voluntary basis to respond to potentially life-threatening calls. I am assured that all ambulance trusts are aware of their responsibilities in this area and regularly review rostering arrangements to ensure they are robust and optimised to meet current demand patterns. The AACE will ensure that the National Directors of Operations Group is made aware of your concerns and remind them of the need to regularly review rostering arrangements. Additionally, I am advised that NHS Improvement intends to write to all ambulance trusts in England to ask them to reflect on the Regulation 28 Report and their own governance procedures, in particular to review rota management including the scheduling of meal breaks to ensure adequate operational cover is provided at all times. I hope this reply is helpful. Thank you for bringing the circumstances of Miss Richmond’s death to our attention. Msn janet Co STEVE BARCLAY ASSOCIATION OF AMBULANCE CHIEF EXECUTIVES Association of Ambulance Chief Executives 3° floor 32 Southwark Bridge Road London SE1 9EU T: 020 7783 2043 E: info@aace.org.uk W: www.aace.org.uk Rachel C Griffin H M Senior Coroner County of Dorset Town Hall Bournemouth BH2 6DY 10 January 2018 Dear Dr Griffin, Thank you for your letter dated 17"" November regarding your Regulation 28 report to Prevent Future Deaths Kathryn Verina Richmond. Within your letter the area of concern you have raised is as follows: e Due to the non-staggering of shift patterns of ambulance crews within Ambulance Service Trusts, there could be increased delays in attending emergency calls due to ambulance staff taking meal breaks at the same time. e | therefore request that a review is undertaken of the guidance given to Ambulance Service Trusts regarding the structuring of their rota system to stagger shifts which in turn will stagger meal breaks to ensure as many resources possible are available at any one time. In preparing our response we have also been in contact with South Western Ambulance Service (SWAST) and have reviewed their response to your concerns and the actions they have taken internally to address those concerns. Clearly there were two main issues in this tragic incident the first involving the way in which the incident was managed internally by the SWAST Emergency Control Centre and secondly the availability of ambulances associated with crews being on protected meal breaks. These issues have been addressed internally by SWAST as part of their response to this incident. Whilst you have indicated that you are satisfied that lessons have been learned in SWAST and changes have been made which adequately address your concerns you remained concerned that similar issues could occur in other Ambulance Trusts nationally. Firstly, can | be clear that the Association of Ambulance Chief Executives (AACE) has no power to mandate Ambulance Trusts nationally to make changes to their operating practices which remain a matter for individual trusts and their respective Boards. That said AACE can and does act as a national co-ordinating voice on many issues of policy and practice and importantly collates information on serious untoward incidents and the lessons learned from them. We maintain a database of such incidents and share outcomes from them widely with the National Ambulance Medical Directors Group (NASMeD) and the National Chairman: Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE Directors of Operations Group (NDOG). This is to ensure that learning within an individual Trust which might have national implications is shared across all Trusts allowing action to be taken where necessary to avoid similar incidents occurring. This is always done when a Coroner issues a Regulation 28 report. Turning to your areas of concern we will ensure that the lessons learned and the actions taken by SWAST are incorporated into our national database of Regulation 28 reports and that both groups take on board the learning from the incident. The changes which SWAST have made in the way in which they managed the emergency call may have been specific to SWAST but we will ensure that those issues and the subsequent changes are shared nationally to allow other Trusts to review their procedures internally to satisfy themselves that their internal control room processes are satisfactory. In terms of the staggering of meal breaks all ambulance services are aware of the need to do this as much as possible and regularly review their rostering systems to stagger start and finish times and hence their meal break ‘windows’. There is a balance to strike which needs to give Trusts the ability to allow emergency crews to have a meal break which they are legally and morally entitled to in order to protect their health and well-being whilst at the same time safeguarding emergency cover to ensure appropriate response times for patients. In addition, all ambulance trusts have the ability to ask crews to interrupt their meal break to attend patients who are life threatened and whilst this is a voluntary system it will have been agreed locally in each case with ambulance staff and their trade unions. In my experience, this works well and dedicated ambulance staff will invariably interrupt their meal break to respond to such patients. The Department of Health and NHS England do not issue specific guidance to ambulance Trusts on the structure of their rostering systems or their meal break arrangements. These remain a matter for individual Trusts to negotiate locally. That said, all Trusts are aware of their responsibilities in this area and regularly review those arrangements to ensure they are robust and are optimised to meet current demand patterns. AACE will ensure that the National Directors of Operations Group (NDOG) is made aware of your concerns associated with this tragic incident and remind them of the need to ensure that this is done on a regular basis. | hope you will agree that this addresses the areas of concern that you have raised. Yours sincerely D.C. Marsh. Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASIi Chief Executive, West Midlands Ambulance Service NHS Foundation Trust Chairman, Association of Ambulance Chief Executives Chairman: Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
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