Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0198, written 17 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2019 |
|---|---|
| Reference | 2019-0198 |
| Deceased | Oliver Hall |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chair of the Association of Ambulance Chief Executives Waterfront Business Park, Waterfront Way Brierly Hill West Midlands DY5 1LX. Sir Andrew Dillon National Institute for Health Care Excellence 4 City Tower Piccadilly Plaza Manchester M1 4BT. Dorothy Hosein Chief Executive, East of England Ambulance Service East of England Ambulance Headquarters Whiting Way Meibourn Royston SG8 6EN. 1 | CORONER | am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 2 | CORONER’S LEGAL POWERS t 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 ist August 2016 | commenced an investigation into the death of Oliver Hall The investigation concluded at the end of the inquest on 7 June 2019. The conclusion of the Inquest was that the death was the result of:- Natural causes contributed to by neglect. The medical cause of death was confirmed as: 1(a) Meningococcal septicaemia 4 | CIRCUMSTANCES OF THE DEATH Oliver Hail was a six-year old boy who died suddenly on the 24 Oct 2017 after becoming acutely unwell on the 23 October 2017. At the time of his death Oliver had been admitted to the James Paget University Hospital, Gorleston, Norfolk, although he resided in Haverhill, Suffolk. Oliver became unwell on the morning of 23" October 2017 when he became lethargic, photophobic, had a sore neck, a temperature which was resistant to Calpol and Calprofen and had developed a rash which his mother felt was non-blanching. BE caic her GP just before 10am and requested an appointment, emphasising that her child was unwell with a temperature which was not responding to medication. She was advised the earliest appointment was at 3.50pm that afternoon but she was to call back if there was any change in circumstances. Following a further call to the GP practice, HE contacted the NHS 111 number who, on hearing of Oliver's symptoms, sent an ambulance. The NHS Pathway System recorded a disposition for the call relating to Oliver as ‘emergency ambulance response for septicaemia’ The ambulance crew arrived at around tp i cescrived her son’s symptoms as outlined above. She told them she was concerned that her son had meningitis. The ambulance crew completed a full set of observations (excluding blood pressure). Upon arrival Oliver's pulse rate was 137 bpm and after approximately 15 minutes this settled to 120 bpm. The ambulance crew said that Oliver did not have meningitis because his rash disappeared under pressure. Oliver’s mother said the edges of the rash blanched and they were in effect only partially blanching. Oliver also had one purple raised area on his arm that did not blanch which the crew thought may have been from the result of trauma. The ambulance crew said Oliver didn’t need to go to hospital but agreed to take him to his GP such was anxiety as to her son’s condition. They arrived at the GP practice at around 2.30pm. Initially a trainee GP saw Oliver in the presence of his mother and both of the ambulance crew. Again, mentioned her concerns regarding meningitis with the GP taking the history from the paramedics. The trainee GP took Oliver's temperature but did not record any of Oliver's other vital signs, accepting these were normal from the ambulance crew. Upon seeing the non-blanching purple mark on Oliver's forearm the trainee GP interrupted his examination to seek assistance from his training supervisor. Both doctors returned but a physical top to toe examination was not completed. The mark on Oliver's arm was assessed by the second GP, who also briefly looked at a maculopapular rash on his leg. A group decision by the four medical personnel present was made that Oliver was well enough to go home. Almost one hour had passed since Oliver's vital signs had been taken That evening, Oliver's spots were getting worse. MM decided to take her son back to the GP who recognised a meningococcal non-blanching rash at 6.45pm. The GP immediately gave Oliver an injection of antibiotics and called 999 for an ambulance at 6.50pm. After a thirty minute wait the GP called 999 again and was told there was ‘no resource available’. HR ecciced not to wait and she and her husband drove Oliver straight to hospital, arriving at the James Paget University Hospital at around 8pm. Tragically, despite the best efforts of the medical staff at the hospital, Oliver passed away in the early hours of 24'" October 2017. 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 could occur unless action is taken. In the circumstances itis my statutory duty to report to you; the MATTERS OF CONCERN as follows. — 1. Itis apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground. In Oliver's case a non-cliniclan NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver's actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician. In response to their algorithms the NHS 111 Service Implemented a disposition of an ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service. However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information. The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’. Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver. 2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call. It was identified, that in a septicaemia case similar to Oliver's (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2. As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time In 9 out of 10 cases). Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less. Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidiy deteriorated. As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating. i H 3. it was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee. This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child. Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normai range for a six-year-old child. The health professionals involved in Oliver's case said they had relied on this guidance. However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response. The health professionals involved in Oliver's case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above. Therefore, it is apparent that the significance of Oliver’s heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment, likely to be due to the nature of the conflicting guidance as detailed above. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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, namely by 12 August 2019 1, the Senior Coroner, may extend the period if | consider it reasonable to do so. 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 | have sent a copy of my report to the Chief i rested C24 111 Service, | am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 47% June 2019 Nigel Parsley NS
3 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.
East of England Ambulance Service NHS Trust Norwich office Hospital Lane Hellesdon Norwich Norfolk NR6 5NA Tel: 07525 906775 31% August 2019 Dear Mr Parsley, Re: Regulation 28 — Oliver Hall (17" June 2019) | am writing to you following the inquest of Mr Oliver Hall 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. Process of the transfer of information regarding a patient’s original disposition by the NHS 111 service to the Ambulance service and the treating clinicians, the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with relevant information. The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system, some of which also use the same triage system (Pathways) as UK 111 providers. The initial stage of this consultation is to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources using the existing technology. Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways. The current system will not identify to a medical professional a delay which is outside (just under) the category for that call, for example a call is made by a medical professional requesting an ambulance and one is not immediately available they will be informed of an anticipated response time outside of the key performance times for that category of call. For a C2 the medical professional will only be told if the anticipated delay will be 40 minutes or longer. As heard in erronpemr evidence at the inquest communication had been sent to key stakeholders, including the Clinical Commissioning Groups, regarding the Ambulance Response Program (ARP) call categories in September 2018. However, he was unable to find evidence that GP's in the region had received further communication regarding how these new categories related to 999 calls made by Health Care professionais. Interim Chief Executive: Dorothy Hosein Chair: Nigel Beverly www. eastamb.nhs.uk The Trust, along with all UK Ambulance Trusts, will shortly be implementing the National Framework for Healthcare Professional Ambulance Responses. The aim of this framework is to standardise nationally how calls from HCPs are triaged and responded to in line with the ARP call categories and to identify | those patients who require immediate clinical intervention as well as transportation. Further information can be found at: hitos://www.england.nhs.uk/publication/healthcare-professional-ambulance-responses-framework/ The Trust currently is aiming to implement this framework on the 24!" September 2019 and as part of this implementation key stakeholders, such as Clinical Commissioning Groups and Health Care Professionals (HCP) across the region, will receive updated and comprehensive guidance including the call categories associated with HCP calls. A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year. The National Institute for Health and Care Excellence (NICE) has guideline NG51 -‘Sepsis: recognition, diagnosis and early management’. This guidance was published in July 2016 and updated September 2017. NICE formally recognise and endorse the work and decision support tools of the UK Sepsis Trust. When reviewing the UK Sepsis Trust ‘Sepsis screening tool prehospital (age 5-11)’, red flag sepsis is considered if there is a severe tachycardia, The screening tool goes onto define a severe tachycardia as a heart rate greater than or equal to 120 beats per minute for children aged six to seven years of age. This is further reinforced on the NICE ‘Sepsis risk stratification tool: children aged 5-11 years out of hospital’. Guidance issued by NICE provides clarity surrounding the recognition and identification of high risk criteria in Sepsis. For any patient presenting with high risk sepsis the patient should be urgently seen in an emergency care setting with resuscitation facilities. NICE states that for children aged 5-11 years, low and moderate to high risk criteria could be treated in an out of hospital setting if the condition can be definitively diagnosed and treated. The UK Ambulance Services, Clinical Practice Guidelines 2016 (JRCALC) identify that a six-year-old child would be expected to have a heart rate of 80-120 beats per minute. in the 2016 guidelines, sépsis in children is covered in a section pertaining to febrile illness in children and the guidance not greatly developed. A new 2018 update has just been launched, within this is update there is greater depth of information that, whilst formatted in a different way does broadly align to NICE guidance. | EEAST has, for a number of years followed and endorsed the work of the UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our ‘Clinical Manual’ — an electronic resource available to staff that is designed to augment the guidance offered by JRCALC. Kind regards, aa - holy xQae-——— Dorothy Hosein interim Chief Executive Interim Chief Executive: Dorothy Hosein Chair: Nigel Beverly www, eastamb.nhs.uk
N [ C National Institute for 42 AUG 2019 10 Spring Gardens Health and Care Excellence London SWI1A 2BU United Kingdom +44 (0)300 323 0140 8 August 2019 Nigel Parsley HM Senior Coroner The Coroners Court and offices Beacon House, Whitehouse Road, Ipswich IP1 5PB Our ref: EH105153 Dear Mr Parsley, | write in response to your letter dated 17 June 2019, regarding the death of Oliver Hall. We have considered the circumstances surrounding Oliver’s death and the concerns raised in your report. In particular, the concerns raised regarding the NICE guidance on treatment of sepsis and a perceived lack of clarity over the heart rate which should trigger a medical treatment response in an unwell 6 year oid child. We consider.that the NICE guideline on sepsis: recognition, diagnosis and early management (NG51) is a relevant is a relevant reference in this case. Of particular relevance is recommendation 1.4.5 in the guideline, which says: 1.4.5 Recognise that children aged 5-11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe iliness or death from sepsis: e has objective evidence of altered behaviour or mental state, or appears ill to a healthcare professional, or does not wake (or if roused, does not stay awake) ©. .respiratory.rate: : o aged 5 years, 29 breaths per minute or more o aged 6-7 years, 27 breaths per minute or more o aged 8-11 years, 25 breaths per minute or more o oxygen saturation of less than 90% in air or increased oxygen requirement over baseline « heart rate: o aged 5 years, 130 beats per minute or more www.nice.org.uk | nice@nice.org.uk o aged 6-7 years, 120 beats per minute or more o aged 8-11 years, 115 beats per minute or more o or heart rate less than 60 beats per minute at any age « mottled or ashen appearance « cyanosis of the skin, lips or tongue « non-blanching rash of the skin. This is also set out in table 2, which is titled ‘Risk stratification tool for children aged 5-11 years with suspected sepsis’. The 2 heart rates mentioned in your report are 137 bpm and 120 bpm, both of which should have prompted the clinicians involved to refer to recommendation 1.5.1 of the guideline, which says: 1.5.1 Refer all people with suspected sepsis outside acute hospital settings for emergency medical care!!! by the most appropriate means of transport (usually 999 ambulance) if: « they meet any high risk criteria (see tables 1, 2 and 3) or « they are aged under 17 years and their immunity is impaired by drugs or illness and they have any moderate to high risk criteria. Emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit. In addition to NICE guidance, our website provides access to Clinical Knowledge Summaries (CKS) which set out the current evidence base and best practice on more than 360 common and significant primary care presentations. These summaries are commissioned by NICE, but they are not formal NICE guidelines. They are authored by an external contractor using a development process that has been accredited by NICE. Information in the CKS Meningitis topic has now been reviewed and amended to ensure this topic is consistent with information in the NICE guideline sepsis: recognition, diagnosis and early management (NG51). An improved process for sharing information about new and updated NICE guidelines that impact primary care is being developed. This process will also provide the contractors with more focussed and current information on future NICE releases than is currently available and will ensure CKS topics can be scheduled for review and updated in as timely a manner as possible. Yours sincerely, Sir Andrew Dillon Chief Executive
Association of Ambulance Chief Executives
3rd Floor
32 Southwark Bridge Road
London
SE1 9EU
Tel: 0207 783 2043
www.aace.org.uk
Our Ref: ACM/MF/KAF
Date: 11 August 2019
Mr Nigel Parsley
Senior Coroner
The Coroners Court and Offices
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
Via email: Coroners.service@suffolk.gov.uk
Dear Mr Parsley,
I write in reply to the concerns you raised with me on 17 June 2019 as Chair of the Association of
Ambulance Chief Executives (AACE) through a Regulation 28 PFD report following the inquest of
Master Oliver Hall.
Firstly, we would like to offer our condolences to the family and those affected by this tragic passing.
To clarify, AACE is a private company owned by the English Ambulance NHS Trusts. It exists to
provide ambulance services with a central organisation that supports, coordinates and implements
nationally agreed policy. Our primary focus is the ongoing development of the English ambulance
services and the improvement of patient care. We are a company owned by NHS organisations
and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice
guidelines. AACE is not constituted to mandate or instruct ambulance services however we do
have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs
along with a network of national specialist sub-groups.
I will address your three key concerns in the order given:
1) It is apparent that there is a failure in the process of the transfer information regarding a
patient’s original disposition by the NHS 111 Service to the ambulance service and treating
clinicians on the ground....It was then identified that the current East of England Ambulance
service system does not provide the ambulance crew (and therefore in this case subsequently
the GP’s) with relevant information.
The failure to transfer the most relevant information in this instance is very regrettable. English
ambulance services use a number of different Computer Aided Dispatch (CAD) systems and one of
two authorised triage platforms to assist them in handling emergency calls effectively. From the
narrative report of the inquest, it is clear that information was originally given to the ambulance control
room by the NHS 111 service that was not then fully shared with the ambulance resource deployed.
Association of Ambulance Chief Executives
Managing Director: Martin Flaherty OBE
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Having consulted with our National Heads of Control Services Group, it is apparent that the process
of sharing this information is necessarily selective. This is partly to avoid overburdening
clinicians/responders with excessive or non-relevant information and partly because the mobile data
terminals in responding resources (ambulances or cars) have limits on what can be displayed. The
systems used vary across the country and the exact nature of what is displayed in the vehicle is
determined by the individual ambulance service within the limits of the technology it utilises. We
understand that East of England Ambulance Service has reviewed their local processes to take on
board your concerns.
Although the process and systems are well established, improvements can always be made. I am
pleased to inform you that during 2020/21 elements of the new National Emergency Services Mobile
Communication Programme will be implemented across all ambulance services and this will include
a greater ability to manage information through the new National Mobilisation Platform. This may in
turn allow us to further standardise the types of information displayed on the mobile data terminals in
ambulance vehicles.
2) Your concern regarding medical professionals being able to make an informed decision with
regard to possible delays in ambulance attendance and that under the current system
(highlighted in this case) a medical professional requesting an ambulance will not be told if
the delay is 39 minutes or less
Work has been ongoing over the last two years to improve the handling of emergency calls received
from Health Care Professionals (HCP). NHS England have now published the National Framework
for Healthcare Professional Ambulance Responses which clarifies the new roles and processes. The
section reprinted below is pertinent in this instance
HCP Level 2 (HCP 2) Category 2 (18 Minute mean response time)
This level of response is based on the clinical condition of the patient and their need for
immediate additional clinical care in hospital in an emergency department or acute
receiving unit (i.e. medical or surgical assessment unit, delivery suite).
Patients with a National Early Warning Score (NEWS2) of 7 or greater may trigger a
request for this level of response, as may the opinion of a HCP who has assessed the
patient.
Patients with a NEWS2 of 6 or less may be suitable for an HCP Level 2 response by
exception only and HCPs, where possible, should detail the clinical reason. Examples
in this category may be patients with sepsis, myocardial infarction, CVA, acute
abdomen, acute ischaemic limb, acute pancreatitis, major gastrointestinal haemorrhage
and overdose requiring immediate treatment.
Whilst these calls may be flagged within the Trust CAD system as being from a HCP
(for AQI reporting purposes), they must be presented and displayed in the Trust CAD
system in the same way as Category 2 calls from the public and responded to
accordingly.
In essence, it is the patient’s condition that determines the prioritisation of response so that
a call from an HCP will receive the same level of response as that of a public 999 call –
driven by the clinical condition of the patient.
Association of Ambulance Chief Executives
Managing Director: Martin Flaherty OBE
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call
taker to give accurate information regarding the expected time of arrival of a response.
This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for
a responding ambulance to be diverted from one emergency to another that has been
assessed as more urgent or indeed for a responding ambulance to be flagged down at
another incident they may be passing. For these reasons, call takers do not commit to an
estimated time of arrival, rather they are asked to say ‘help is on its way and please ring
back if the patient’s condition changes’.
3) A lack of clarity was apparent over the current national institute for health care and excellence
on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance
liaison committee, specifically in matters of the pulse rate of 120 in a six year.
Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are
clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be
influential on its own. The attending ambulance staff have been taught that the assessment of the
child with regard to severity of illness and possible causes would be influenced by a range of
observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice
to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only
by doing this that information received can be verified and form part of subsequent decision making.
Ambulance services are all supportive of the clinical guidelines used across the UK and developed
by JRCALC but are fully cognisant that these are guidelines for interpretation as are those published
by other organisations.
Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other
guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their
current guidance for ambulance staff.
I trust you feel that I have answered your concerns fully and thank you for bringing them to my
attention.
Yours sincerely
Professor Anthony C. Marsh
Chairman, Association of Ambulance Chief Executives
CC: Martin Flaherty OBE, Managing Director, AACE
Association of Ambulance Chief Executives
Managing Director: Martin Flaherty OBE
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
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