Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0198, written 25 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jun 2018 |
|---|---|
| Reference | 2018-0198 |
| Deceased | Margaret Stemp |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Darren Mochrie Chief Executive South East Coast Ambulance Service SECAmb HQ, Nexus House, Gatwick Road, Crawley, West Sussex, RH10 9BG 1 CORONER I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 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 INVESTIGATION and INQUEST On 16th January 2018 I commenced an investigation into the death of MARGARET STEMP, aged 91. The investigation concluded at the end of the inquest on 11th June 2018. The conclusion of the inquest was that “Margaret died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention.” 4 CIRCUMSTANCES OF THE DEATH During Christmas 2017 Margaret was staying with her sister who was 97 years old. It appears that around 4.00pm on 27th December both sisters had fallen over and were unable to get up. As a result Margaret’s sister contacted the emergency services and an Ambulance was requested. The Ambulance service was under extreme pressure that day and were unable to send an Ambulance to assist these ladies. As the Ambulance service had not arrived after 7 hours the Police attended and assisted the two ladies and got them off the floor. The Police however indicted to the Ambulance service that they should still attend to check over these two ladies. Despite this at 2.00 am the following morning the Ambulance service, who has still not attended, made a further welfare telephone call to the address. They spoke to Margaret’s 97 year old sister. She advised the Ambulance service that she had been waiting for the Ambulance service for a considerable period of time since and she was now going to bed and no longer needed them. The Ambulance Service closed the call without any clinical oversight of that decision. On 28th December a carer attended the sisters’ address. When she arrived she discovered both ladies again on the floor. Sadly Margaret was found deceased and her sister needed to be taken to hospital. 1 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) That there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours and what would have been considerably longer had the Police not attended. (2) That the Police had to be used to provide the necessary welfare support to these ladies (3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance. (4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 13th August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person namely , Executor of Margaret’s estate. I have also sent it to Chief Constable of Sussex Police 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 25th June 2018 Penelope Schofield, Senior Coroner 2
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.
South East Coast Ambulance Service (NHS | NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust Nexus House Gatwick Road Crawley RH10 9BG Ms P Schofield HM Coroner for West Sussex County Records Office Orchard Street Chichester PO19 1DD 14 August 2018 Dear Madam | write to respond to the Regulation 28 Report you issued on 25 June 2018 following the inquest into the death of Margaret Stemp. | was very sorry to hear of Mrs Stemp’s death, and that we were not able to provide the response that we aspire to when her sister called for help on Christmas Day 2017. | would like to address in turn each of the areas of concern that you have raised: 1. There were insufficient resources to deal with the high number of calls on the day in question The Christmas period, and specifically Christmas Day, is one of the busiest and most challenging times of the year for the ambulance service. We anticipate increased demand and roster increased resources to try to meet that anticipated demand. On Christmas Day 2017, the level of demand was even greater than we had anticipated and for which we had resourced. At times of highest demand, priority is given to patients in an immediately life threatening position. In order to avoid this situation recurring in future periods of very high demand, we have taken the following action: a. We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand. b. We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have + Chairman: Graham Colbert (Interim) Chief Executive: Daren Mochrie QAM Your Service, N aaa purchased 30 second hand ambulances so far this year, to help us to deal with anticipated winter pressures. c. We are, together with our commissioners, carrying out a “Demand and Capacity Review”, which will enable both parties to determine: i. the resources needed to meet the demand on our service, to cope with increased pressure throughout the acute healthcare system, including “out of hours” provision, and ii. how those resources will be provided. d. We have planned a review of our forecasting model, with the objective of better anticipating what resources will be needed for any hour of any day, making provision for system pressures. 2. The Police had to be used to provide the necessary welfare support to Mrs Stemp and her sister | am grateful to the Police for their assistance on this occasion, however | fully accept that the welfare of patients is SECAmb’s responsibility, not that of the Police. Since this incident, we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in a timely manner. | attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while they are awaiting an ambulance. 3. The call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring. 4. There was no clinical oversight of the decision to stand the ambulance down As a result of this incident, the procedure for standing down an ambulance has now been changed. A Support Call Taker can no longer stand down an ambulance. A two-step verification process has been introduced whereby they must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down. | trust that this letter reassures you that we have taken very seriously the issues arising from Mrs Stemp’s incident on 25 December 2017 and that we have put measures in place to ensure that the situation will not recur. Yours sincerely ZF SD rao Daren Mochrie QAM Chief Executive South East Coast Ambulance Service NHS Foundation Trust
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