Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0183, written 31 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 May 2019 |
|---|---|
| Reference | 2019-0183 |
| Deceased | Christopher Williams |
| Coroner | Yvonne Blake |
| Coroner area | Norfolk |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | East of England 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.
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:
Clinical Director
East of England Ambulance Service
NHS Trust
Headquarters
Melbourn Ambulance Station
Whiting Way
Melbourn
Cambridgeshire
SG8 6NA
CORONER |
lam YVONNE BLAKE, Area Coroner, for the coroner area of NORFOLK
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.
1
INVESTIGATION and INQUEST
On 30 January 2019 | commenced an investigation into the death of Christopher
Williams aged 77 years. The investigation concluded at the end of the inquest on 22
May 2019. The conclusion of the inquest was concluded with a narrative conclusion and
| the medical cause of death given as: \
1a) Multi-Organ Failure
1b) Sepsis
1c) Infected Post-Op Wound (Staph Aureus)
2 Obesity, immobility and Hypertension.
CIRCUMSTANCES OF THE DEATH
Mr Williams underwent a day procedure on 19 January 2019 to remove a screw from a
previous foot surgery because of infection developing around the site. He had a popliteal
nerve block and the procedure was uneventful. Two days later on the 22 January 2019
he developed severe pain in that leg making it impossible for him to weight bear. He
called the surgeons secretary and was advised to call his GP which he did. He had also
developed paraesthesia to both legs and worsening back pain. His GP attended and
requested an urgent ambulance since she was concerned about cauda equina. She also
arranged for him to be admitted directly to the ward at the NNUH. She called the
ambulance service at 14:17hrs, she was told it may take up to four hours, a pick-
up time of 15:17 hrs was entered. At 15:20 hrs the Trust called the patient back and was
told that his condition was worsening, however the call handler did not escalate this
information within the control centre and thus no-one else was aware. It is understood
that the call handler also used an incorrect algorithm (haemorrhage) which led to the
wrong questions being used. A further welfare call was made at 17:40hrs but no answer
received so this was escalated to the Duty Officer who subsequently upgraded the call |
to a grade 3. At 19:41 hrs IEEE made a 999-call describing Mr Williams not
being alert and having difficulty in breathing and the cail was upgraded to a category 1.
A RRV and DSA were dispatched at 19:45hrs and arrived on scene at 19:58 and
20:01hrs respectively. Mr Williams was conveyed to the NNUH arriving at 20:59hrs. He
was then kept in the ambulance until 23:56 hrs when he finally entered the Emergency
Department. He was admitted to a surgical ward after preliminary investigations by the
Emergency Department and orthopaedic doctors with a working diagnosis of possible
pulmonary embolus.
His condition worsened rapidly on morning of the 23 January 2019 with hypoxia, acute
kidney injury and tow consciousness. The opinion was that he had sepsis with
worsening heart failure. He was admitted to High Dependency Unit but despite intensive
treatment he died on the 26 January 2019. _ =
CORONER’S CONCERNS
During 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) The amount of time taken for the ambulance to arrive which was markedly
outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition
and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board
the vehicle awaiting a space in the Emergency Department, despite a bed already
arranged several hours before by the GP. This information was unknown to the crew
and resulted in several hours delay in Mr Williams being investigated and treated
which may have contributed to his death by sepsis.
| The Trust's Business Continuity Manager was unaware until the inquest that the call
| handler had erred in failing to escalate and in using the wrong algorithm. He gave
evidence that the Trust does not have an algorithm dealing with neurological deficit only
a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to
both legs and the GP’s concerns about cauda equina this would seem to be a potentially
dangerous gap in the Trust's triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know
why she failed to escalate Mr Williams’ worsening condition and why she used the
wrong algorithm and that the supplier of their IT software (the triage system), were
reluctant to add a neurological algorithm, the reason for this is unclear. When asked the
manager accepted that as the customer surely (the trust) could state that a neurological
algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and
the manager accepted in evidence that he had not made any enquiries about this, prior
to inquest. Again, this failure in communication is one which | feel places other patients
at risk of death and is unacceptable. This is not an isolated incident (death) and it
appears that there are systemic failures within your organisation which should be
addressed.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and the
East of England Ambulance service NHS Trust 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 26 July 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
| | have sent a copy of my report to the Chief Coroner and to the following Interested |
| Persons:
| have also sent it iii. Orthopaedic Surgeon
who may find it useful or of interest.
{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 yoyr response by the Chief Coroner.
}9 | 31 May 2019
5 Thorpe Road
ich NR11UA
|
J
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.
NHS East of England Ambulance Service NHS Trust Norwich office Hospital Lane Hellesdon Norwich Norfolk NR6 5NA Tel: 07525 906775 10" July 2019 Dear Ms. Blake, Re: Regulation 28 — Christopher Williams (31** May 2019) | am writing to you following the inquest of Mr Christopher Williams and the Trusts receipt of a Regulation 28. In order to address your concerns, as outlined in Section 5, | will outline the Trusts current position and areas which are being considered for change/being changed. The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines. Following a review in April 2017 commissioned by NHS England and NHS Improvement recommendations were made on the best service model, pricing review, capacity and demand analysis and the commissioning/contract model. The review was undertaken by Deloittes and ORH, a company specialising in operational modelling for emergency and health services. The findings were published on the 11th May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand. This was factored in to our emergency operations contract with funding released to enable to increase front line staff by 330 full time equivalents by 2020/21. To date the Trust have recruited 491 frontline staff with a further 270 frontline offers of employment in process. To support timely release of Trust resources from hospital sites the Trust has worked with system partners to ensure early escalation of hospital handover delays which is supported in a regional handover protocol and operating procedure. The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm. Emergency Call Handlers work using a triage system called Medical Priority Dispatch Solution (MPDS). This system is designed and owned by the International Academy of Emergency Dispatch (IAED). We work with the IAED to improve standards of triage and to also identify where a protocol does not meet the needs of patients, whilst also understanding that in an emergency environment where 999 calls are triaged by non-clinicians there will be some calls which will need clinical support/ intervention in reviewing the response. The Trust’s Audit and Training Manager will be shortly meeting the IAED’s UK Manager, following which the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls. Interim Chief Executive: Dorothy Hosein Chair: Sarah Boulton www.eastamb.nhs.uk This proposal will also be sent through to the National Ambulance Services Medical Directors (NASMeD) for their consideration and support. In the case of Mr Williams, whilst there was no protocol which addresses neurological deficit, this had no negative detriment to the care provided or the response assigned by the AOC as the highest level of response was achieved (Category 1). As stated in SE <p: we have re-enforced the escalation process in the initial training with Call handlers and also through a series of 1-2-1 sessions with existing staff. When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis. In the initial call the HCP called and asked for the patient to be conveyed to the Norfolk and Norwich University Hospital, the clinician requested for the patient to be taken to the Emergency Assessment Unit. When we received a 999 call from the property identifying that the patient’s condition had deteriorated the dispatcher allocated on the new call as it was of a higher priority, in line with 20180525 Ambulance System Indicators. Due to the dispatcher assigning to the new call it is apparent that information pertaining to the destination of the patient was omitted as the information is sent to the crew using data. We are in communications with the CAD supplier to make an alteration to the duplication process which would allow pertinent information to be transferred from the original call into the call which EEAST are “running on”. Having a technical solution will minimise risk of human error. As an interim arrangement we will ask all dispatch staff to ensure that any pertinent information of this kind is transferred into the new call, until there is a technological resolution in place. We are also working with our colleagues in other Ambulance Services who use the same CAD to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources. Should you have any further questions or if you would like any of the areas outlined above expanded upon please do not hesitate to contact me. Please also contact me if you would like to accept the offer to visit the Emergency Operations Centre to arrange a date and time that suits you and your staff's needs. Kind regards, a My Aw—— Dorothy Hosein Interim Chief Executive Interim Chief Executive: Dorothy Hosein Chair: Sarah Boulton www.eastamb.nhs.uk
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