Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0031, written 24 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jan 2019 |
|---|---|
| Reference | 2019-0031 |
| Deceased | Olive Johnson |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| Category | Emergency services related deaths (2019 onwards) |
| 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 (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 EMAS…………………………………… 2 …………………… 3 …………………………………… 1 CORONER I am Paul S Cooper Assistant Coroner for the area of Lincolnshire 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 18/05/2018 I commenced an investigation into the death of Olive JOHNSON aged 97. The investigation concluded at the end of the inquest on 23 January 2019. The conclusion of the inquest was: I a Acute Myocardial Infarction I b Left Anterior Descending Coronary Artery Thrombus I c - II - 4 CIRCUMSTANCES OF THE DEATH The deceased died within 24 hours of being admitted to Pilgrim Hospital , Fishtoft ,Lincolnshire on 11th May 2018 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: a) Why were no first responder's called out in relation to the deceased? b) How many occasions have EMAS exceeded their response times since 01/01/2108 to date? c) Is it fair that if a patient is regraded whilst awaiting an initial response the total time from the initial call to the regrading is cancelled out? d) Do EMAS believe they have enough conveying resources to meet their response targets? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 21 March 2019. 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 Persons Nephew - …………………………………………………………………………………………………………………… 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: 24th January 2019
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.
Mr P S Cooper Assistant Coroner Lincolnshire County Council Coroner’s Service Unit 1, Endeavour Park Boston, Lincs PE217TQ Dear Mr Cooper INHS| East Midlands Ambulance Service NHS Trust Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY PALS telephone: 0333 012 4216 Head office telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk 21 March 2019 Re: Report to Prevent Future Deaths: Olive Johnson Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 23 January 2019, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Ms Olive Johnson. | would like to assure you that the Trust takes all matters relating to patient safety extremely seriously. In particular, matters arising from Coroners’ Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed by the Incident Review Group and Lessons Learned Group. Matters of Concern: a) Why were no First Responders called out in relation to the deceased? On the day in question, there were three voluntary Community First Responders logged on duty. The role of a Community First Responder is to provide pre-ambulance arrival assistance to patients within their community. One responder was committed on another call; one responder was responding to cardiac and respiratory arrests only and the third responder was located over 20 miles away. The Community First Responder role is not designed for the responder to travel excessive distances out of their community. As the third responder was over 30 minutes away at normal road speed, this would be considered too far away to travel to attend Ms Johnson. b) How many occasions have EMAS exceeded their response times since 01 January 2018 to date? During the period 1 January 2018 to 31 January 2019, we have exceeded our response times as follows: Respond | Develop | Collaborate East Midlands Ambulance Service NHS Trust c) Is it fair that if a patient is regraded whilst awaiting an initial response, the total time from the initial call to the regrading is cancelled out? It has been decided from a national perspective that when a call is re-categorised to a higher priority, the time frame for the resource to be conveyed commences from the time of the re-grading. d) Does EMAS believe they have enough conveying resources to meet their response targets? A jointly commissioned, independent “demand and capacity review’ identified a gap between the resources presently available, and what was needed to deliver national performance standards for ambulance services. In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019- 2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m extra funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms. The funding will directly address the gap identified in the demand and capacity review, and is expected to result in a stepped improvement in the Trust’s ambulance response times and consistency of response across all areas of the East Midlands region. The additional money will be invested in the right level of resources to enable the Trust to respond more quickly and consistently to 999 calls and urgent GP requests and to achieve national standards at a county level, which came into force for all ambulance trusts in autumn 2017. | hope that the measures set out in this letter provide you with the appropriate level of assurance in relation to our commitment to continuous improvement of services. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above. Yours sincerely Richard Henderson Chief Executive Respond | Develop | Collaborate
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