Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0281, written 31 Jul 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 Jul 2019 |
|---|---|
| Reference | 2019-0281 |
| Deceased | Fern-Marie Choya |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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INHS| London Ambulance Service NHS Trust Executive Office Headquarters 220 Waterloo Road London H lI Ms Mary Hasse’ &€1 85D HM Senior Coroner for Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP Tel: 020 7783 2046 23 August 2019 Dear Ms Hassell, Regulation 28: Prevention of Future Deaths Report — Fern-Marie Choya Thank you for your Regulation 28 Prevention of Future Deaths (PFD) report dated 31 July 2019. | would like to take the opportunity at the outset of my letter to offer my sincere condolences to Ms Choya's husband and family. Thank you also for informing the London Ambulance Service NHS Trust (LAS) of the concerns you identified at the inquest into Ms Choya’s death. Having reviewed our original evidence in this case, following receipt of your PFD report, it has unfortunately become clear that the LAS provided inconsistent evidence in relation to its involvement in Ms Choya's death. The clinical opinion prepared by the LAS to contribute to the Healthcare Safety Investigation Board's (HSIB's) report and provided to yourself concludes “It is notable that at 09:08, EAC A, contacted the sector desk in the control room, to request for further help, and to place a pre alert information call to the emergency department. During this call he alerted the dispatch desk to the information that informed the pre alert, and also mentioned the patient was pregnant.” However, on reviewing the recording of the call in conjunction with the transcript, it has become clear that this was not an accurate representation of the communication between the crew and the Emergency Operations Centre (EOC). The salient point of the discussion between crew (G305) and the EOC is as follows: “G305 - Current GCS is 3, over, and our ETA will be erm, 8 minutes, over. EOC - Lovely, erm, so this is erm, pregnant, with a, did you say query PE, over. G305 - A query seizure or something EOC - All noted, passing for you now Transmission Ends” Whilst this transcript was previously provided to you prior to the inquest, a further copy is enclosed, for ease of reference. It is now evident from the tape and the transcript that the crew did not confirm to the EOC that Ms Choya was pregnant and that the EOC did not pursue and confirm this possibility either; this is why that information was not passed on in the pre-alert information call to the emergency department as suggested in the clinical opinion. The LAS will be informing the HSIB about the inaccurate information that was fed into its report and will be providing the HSIB with details of the actions that the LAS has taken to avoid a recurrence of this. At the same time, an appropriate review of the LAS clinical opinion provider will be undertaken to highlight the importance of checking call details with the EOC, and in order to ensure accuracy and consistency in the Trust's approach in feeding into other organisations’ repagtt. The case had previously been considered by the Trust's Serious Incident Group as a potential serious incident. At that time it was not declared as such because the information relating to the call was not available; the decision was taken to work with HSIB and continue the investigation in order to bring the results of this back to the Group following the Inquest. These has now been received by the Group which has retrospectively declared this a serious incident. .. The matters of concern you identified are as follows: 1. The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice. However, they failed to include in that alert the information that Ms Choya was pregnant. This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene. Notwithstanding the fact that our further review of the transcript has indicated that it was both the crew and the EOC, rather than the EOC alone which failed to pass on the information that Ms Choya was pregnant, the LAS acknowledges that, had the correct information been passed, the focus of Ms Choya’s treatment may have been different. Prior to the Inquest, a meeting was held with the crew regarding this incident and feedback provided during this de-brief meeting. In addition, the crew are also to attend an observation session in the EOC for learning purposes (to be completed by 14 October 2019). Furthermore, the relevant Clinical Team Leader will be reviewing, with the crew, what they have learnt from that session and seeking confirmation that they will be following a structured approach every time they share information with the EOC about patients or hand them over to an emergency department in the future. To support crews and the EOC, the LAS has also recently re-issued guidance (on 12 August 2019) to clarify the relevant details expected during pre-alert calls, to ensure that the appropriate clinical team is present on a patient's arrival. This guidance stipulates the CASMEET mnemonic (please see attached Bulletin). As a result of our learning from Ms Choya’s death, the LAS has extended this guidance to include a request from the EOC for ‘any other specific and critical information’ at the end of the radio transmission when they repeat the information provided back to the crew. Operational staff will be made aware of this change. 2. Onarrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. The LAS currently utilises the SBAR tool for all patient handovers (Situation, Background, Assessment, and Recommendation). This enables crews to be confident that they have passed relevant information onto emergency departments when handing over patients, even in the most stressful scenarios. However, the importance of relaying the important medical information at handover has been stressed to the crew who provided care to Ms Choya, as part of the feedback and de-brief meetings referred to above. The LAS has liaised with tertiary centres to develop a comprehensive handover procedure in relation to cardiac arrests, ensuring that relevant and key important clinical informatiogyig shared with the receiving team. As part of this handover procedure, receiving teams are expected to observe a 30 second “hands off eyes on time” period to ensure quiet whilst vital information is conveyed using the ATMIST AMBO (age, time, mechanism/medical complaint, injuries/information related to complaint, signs, treatment — allergies, medication, background/history, other information) mnemonics. The LAS will be rolling out the extension of this handover tool/procedure to all receiving centres, as per the attached handover documents. Work will also be done to ascertain the feasibility of establishing a handover audit mechanism in the specification of the Electronic Patient Care Record (EPCR) that is being developed by the LAS alongside the introduction of its replacement Computer Aided Dispatch (CAD) system. We have also already recognised a gap in understanding of maternity calls, between the EOC, frontline operations and maternity units. As such, the LAS has undertaken extensive learning around handovers and this will continue as part of the joint learning with the Whittington Hospital. The LAS uses ‘Managing Maternity Emergencies in Pre-Hospital Setting’ which was established in 2015. The LAS Practice Leads for pre-hospital maternity care updated this joint training in April 2019 to include staff working within the EOC. This was initially in response to identified areas for improvement regarding the communication and management of maternity calls from midwives working in the pre-hospital setting. Every multi-professional maternity training now involves operational road staff, EOC staff and midwives as well as maternity support workers. Since April 2019, the LAS facilitated three joint training sessions which included EOC staff. These took place as follows: ¢ 30April 2019 - Chelsea and Westminster Hospital and Fulham Ambulance Station. ° 16 May 2019 - Guys and St Thomas's Maternity Unit and Westminster Ambulance Station. e 24 July 2019 - Guys and St Thomas’ Maternity Unit and Westminster Ambulance Station. We have discussed Ms Choya’s case with the Whittington Hospital at Clinical Lead, Medical Lead and Director level and are in the process of arranging a session with the Whittington Hospital in light of the learning from Ms Choya's death. 3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya. This is an issue for the emergency department at the Whittington Hospital; however, the LAS anticipates that a number of the measures that have been set out above will assist in ensuring that patients such as Ms Choya receive more timely care in the future. We will as mentioned above, seek to hold a joint training session with the Whittington Hospital in order to ensure that any further learning is shared between the two organisations. An action plan has been devised in order to progress and complete the issues that have been identified in this case, this can be found attached. Yours sincerely, igeb OO Garrett Emmerson Chief Executive Officer
Dr Clare Dollery Executive Medical Director Whittington Health NHS Trust Whittington Hospital Magdala Avenue London N19 5NF 23/08/2019 HM Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Private and Confidential Dear Senior Coroner Hassell, Re: Regulation 28 Prevention of Future Deaths (PFD) I am writing to respond to the Regulation 28 Prevention of Future Deaths (PFD) report for Fern-Marie Choya. This response is written on behalf of Whittington Health, however we have shared the actions and recommendations with London Ambulance Service to ensure all learning is shared. Matter of concern 2 (Whittington Health) – On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. Matter of concern 3 (Whittington Health) – Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya. The actions we have taken in response to these concerns are as follows; 1. We have modified the Emergency Department ‘Priority call information sheet’ which is used when recording call details received from London Ambulance Service red phone. The sheet now includes a prompt for Whittington Health staff to ask if the patient is pregnant, where relevant. This new sheet replaced the original form in the Emergency Department on 19th August. A copy of the sheet is included in Appendix A. 2. A set of criteria have been developed to determine if an obstetric call needs to be initiated prior to patient arrival. The Trust already has a process in place for trauma calls, which has now been expanded to cover obstetric callout criteria. In agreeing the criteria, advice was sought from Emergency Department colleagues in other trusts to see if similar systems were already in place and the final criteria were agreed jointly with our obstetrics and emergency teams. The new criteria have now been launched in the Emergency Department. A copy of the criteria is included in Appendix B. 3. We are planning a simulation exercise with London Ambulance Service to prepare staff on how to receive a critically unwell obstetric patient. The details of this are being planned but we aim to run the drill in September. This will build on lessons from sessions London Ambulance service has run with other acute Trusts. Following the first simulation, a programme will be established for future drills to ensure continuous ongoing shared learning. 4. Further work is being undertaken across the Trust in order to standardise handover between clinicians by using the “SBAR” format (Situation, Background, Assessment, Recommendation). This has already been included in the new junior doctor’s induction to the Emergency Department and is being designed into the electronic clinical notes that are used to hand over a patient at any point from presentation to discharge. In preparing this response clinical and governance teams and the Medical Directors of both LAS and Whittington Health have shared information to ensure shared learning and close working for the future. Please do not hesitate to contact me if you would like any further information. Yours sincerely Dr Clare Dollery Executive Medical Director Cc: Siobhan Harrington, Chief Executive, Whittington Health , Chief Nurse and Director of Patient Experience, Whittington Health Chief Operating Officer, Whittington Health , Care Quality Commission, Whittington Health Dr Fenella Wrigley, Executive Medical Director, LAS , Head of Quality Governance, Whittington Health
Regulation 28: Prevention of Future Deaths report Fern-Marie CHOYA (died 25.02.19) THIS REPORT IS BEING SENT TO: 1. Dr Fenella Wrigley Executive Medical Director London Ambulance Service NHS Trust 220 Waterloo Road London SE1 8SD . Dr Clare Dollery Executive Medical Director Whittington Health NHS Trust Whittington Hospital Magdala Avenue London N19 5NF CORONER lam: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP CORONER’S LEGAL POWERS | make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. INVESTIGATION and INQUEST On 1 March 2019, | commenced an investigation into the death of Fern- Marie Choya aged 40 years. The investigation concluded at the end of the inquest yesterday. At inquest, | made a narrative determination, a copy of which | now enclose. CIRCUMSTANCES OF THE DEATH The medical cause of Ms Choya’s death was: hypovolaemic shock due to massive intra abdominal bleeding (emergency laparotomy on 25.02.19) rupture of the abnormal gravid uterus monochorionic diamniotic pregnancy (18/40) CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving tise 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 London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding: the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice. However, they failed to include in that alert the information that Ms Choya was pregnant. This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene. . On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. . Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe that you 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 30 September 2019. 1, 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 | have sent a copy of my report to the following. HHJ Mark Lucraft QC, the Chief Coroner of England & Wales Care Quality Commission for England Association of Ambulance Chief Executives (AACE) National Ambulance Service Medical Directors (NASMeD) husband of Fern-Marie Choya | 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. DATE SIGNED BY SENIOR CORONER 31.07.19 WEta—ol
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