Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0300, written 16 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2019 |
|---|---|
| Reference | 2019-0300 |
| Deceased | Arthur Jepson |
| Coroner | David Urpeth |
| Coroner area | South Yorkshire (West) |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | Yorkshire Ambulance Service NHS Trust |
| 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 THIS REPORT IS BEING SENT TO: 1. Chief Executive, Yorkshire Ambulance Service, Trust Headquarters, Brindley Way, Wakefield 41 Business Park, Wakefield, WF2 0XQ 1 CORONER I am David Urpeth, assistant coroner, for the coroner area of South Yorkshire West 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 3.10.18, an investigation into the death of Arthur William Jepson was commenced. The investigation concluded at the end of the inquest on 16.9.19. The conclusion of the inquest was Natural Causes 4 CIRCUMSTANCES OF THE DEATH Mr Jepson suffered stomach pain and called 999. The evidence was that the initial call was made at 15.32. That call was initially triaged as Category 5 but when the paramedic telephoned an hour later the matter was re classified at category 3. The ambulance arrived at 19.31. . CORONER’S CONCERNS 5 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. – During the inquest, evidence showed:- 1. 2. that the pressure on resources was high that day. that a review at the two hour point should have taken place to ascertain if the matter needed re categorisation. 3. Such a review didn’t happen. 4. Whilst the evidence at inquest was that this is unlikely to have changed the outcome in this case, it was a concern to me that it could be in another case. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th November 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 to all Interested Persons :- The family of Mr Jepson, the deceased. CQC 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 16.9.19 SIGNED BY: DAVID URPETH, ASSISTANT 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.
INHS Yorkshire Ambulance Service 20 November 2019 NHS Wurt PRIVATE & CONFIDENTIAL Chief Executive’s Directorate Mr. D. Urpeth Ambulance Headquarters Assistant HM Coroner for South Yorkshire (Western) Springhill Brindley Way Wakefield 41 Business Park Wakefield WF2 0XQ Sent by e-mail only Tel: 0333 130 0550 Dear Sir, Re. Prevention of Future Deaths report —- Mr. Arthur Jepson | write further to your letter enclosing your prevention of future deaths report following the inquest of Mr. Arthur Jepson, which the Trust received on 25 September 2019. Firstly, may | extend my apologies on behalf of Yorkshire Ambulance Service NHS Trust to the family of the late Mr. Jepson. Following Mr. Jepson’s inquest on 3 October 2019 at the Medico-Legal Centre, Sheffield you outlined your concerns regarding the apparent lack of a review of Mr. Jepson’s call following a two hour period to ascertain whether the incident needed re-categorisation. Although as described in your letter, you felt that given the evidence heard at the inquest, it would have been unlikely to have changed the outcome for the late Mr. Jepson, you were concerned that this may have an impact upon other patients’ care. As outlined in the Trust's letter to you dated 4 October 2019 from the Legal Services Department, it is regrettable that information regarding the Trust’s call-back standard operating procedure was not alluded to in written and oral evidence and to provide assurance that there was, and continues to be, a procedure in place to ensure that incidents are reviewed once the expected response timescales had been exceeded. As was heard within the oral and written evidence at the inquest, the Trust was experiencing high demand at the time of Mr. Jepson’s call, especially within the area of South Yorkshire and unfortunately a call-back was not made to Mr. Jepson once two hours had elapsed for which | apologise. Your letter has prompted the Trust to refresh its approach to dealing with such matters and to build upon work already ongoing within the Emergency Operations Centres (“EOCs’) with improving its processes and procedures. As outlined within the letter from the Trust on 4 October 2019, there is work currently ongoing to create a centralised Senior Clinical Advisor standard operating procedure (“SOP”) and the current call-backs and comfort calls SOP has been identified as forming an integral part of this revised central SOP. ak 489, MINDFUL S$ 0/e7;* www.yas.nhs.uk EMPLOYER “A Ai “Saar WOSry, The new centralised Senior Clinical Advisor standard operating procedure was ratified at an internal governance meeting on 19 November 2019 and it is anticipated that the new procedure will be in place by early December 2019. It is intended that at times of high demand, or for patient care, it may be appropriate for senior clinical advisors (“SCAs’”) to undertake call backs and comfort calls. To provide a structured approach to this process a filter exists within the computer aided dispatch (“CAD”) system and this filter allows for incidents which have exceeded their expected timeframe to be viewed separately from other incidents awaiting dispatch by the allocated clinician. In addition to this, any incident likely to breach the mean time will be visible. The SCA should speak with the patient wherever possible and should introduce themselves and ask if anything has changed since the initial call was made. If no change has occurred, the SCA will explore the options of alternative transport however if this is unavailable or not a possible option, then the SCA will reassure the patient that an ambulance response will be with them as soon as possible and advise them to call back via 999 if the patient’s condition deteriorates. If there has been a change in the patient's conditions then a Manchester Triage System (“MTS”) triage must be completed by the clinician and re-categorised as appropriate, using a dedicated upgrade / downgrade code. It is expected that Category 1 incidents with excessive response times will be assessed and given support by the dedicated Category 1 Clinician separate to the process outlined above. In order to gain assurances that the processes are effective, reporting mechanisms shall be put in place to ensure that the revised call-back procedures are being undertaken and ensuring that any excessive incidents receive regular contact to establish whether the Trust’s response is still appropriate and safe. | trust this letter is to your satisfaction and once again, my sincerest condolences to the family of Mr. Jepson. Yours faithfully, of Rod Barnes Chief Executive Officer Yorkshire Ambulance Service NHS Trust MINDFUL 3 EMPLOYER * we
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