Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0340, written 10 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2019 |
|---|---|
| Reference | 2019-0340 |
| Deceased | Ian Bean |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Emergency services related deaths (2019 onwards) · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
Confidential Mr AJ Cox Acting Senior Coroner for Cornwall and the Isles of Scilly The New Lodge Newquay Road Penmount Truro TR4 9AA Dear Mr Cox 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 4 December 2019 Regulation 28 - Prevention of Future Deaths report regarding the case of Mr lan Thomas Trevor Bean deceased Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 10 October 2019, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Mr lan Bean. | 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 Deaths Reports, are discussed by the Incident Review Group and Lessons Learned Group. Matters of Concern: You have raised concern that an ambulance was wrongly dispatched to the address of Mr Bean’s father in Nottingham, rather than to Mr lan Bean’s address in Cornwall. Sequence of Events On 14 April 2018, Mr Bean’s father rang East Midlands Ambulance Service (EMAS) at 1940 hours to request an ambulance for his son. Mr Bean provided the Emergency Medical Dispatcher (EMD) with details of his son’s address in Cornwall. In April 2018, when a caller dialled 999 from a landline, the Computer Aided Dispatch (CAD) system, which is used by EMDs, automatically imported the caller's address into the CAD. On this occasion therefore, the CAD system contained details of both Mr Bean Senior's and his son's address. Respond | Develop | Collaborate Page 1 of 2 The EMD acted appropriately by promptly telephoning South West Ambulance Service Trust (SWAST) at 1943 hours and the details of Mr Bean’s call were passed to them, including information regarding Mr lan Bean’s overdose and self-harm. The call ended at 1949 hours. However, a Dispatch Officer incorrectly allocated a resource to Mr Bean’s address in Nottingham. Unfortunately, they did not notice the Cornwall address, or the notes that the EMD had entered in the incident log that that call had been passed to another Ambulance Trust. Whilst there was no delay in an ambulance being requested to be dispatched to Mr lan Bean, a mistake occurred in an ambulance also being dispatched to Mr Bean Senior's address in Nottingham. Current system We continually review our systems and processes to ensure that we are delivering the best possible service to our patients. We have worked with other Ambulance Trusts to develop call-passing technology. Since 13 December 2018, calls are passed through an electronic gateway, which negates the need for verbal handover. The new system will only permit one address to be added onto the electronic gateway and the process followed now is that Mr Bean Senior's address would be added to a notepad on the file, which is not immediately visible on the screen. This is a more efficient method of passing calls and will avoid a similar situation occurring in the future. | can only apologise to Mr Bean’s father that an ambulance arrived at his address and for any additional distress caused to him. | hope that this response provides the necessary assurance that no delay occurred in us transferring his request for an ambulance to attend his son to the SWAST. | hope that this response provides 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 Page 2 of 2
Information Classification: CONFIDENTIAL REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) lan Thomas Trevor BEAN, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr R Henderson, Chief Executive, East Midlands Ambulance Service, Horizon Place, Mellors Way, Nottingham NG8 6PY CORONER | am Andrew Cox, Acting Senior Coroner for the coroner area of Cornwall &The Isles of Scilly 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. INVESTIGATION and INQUEST On 26 April 2018, an investigation was opened into the death of lan Thomas Trevor Bean who died on 14/4/18 at Liskeard in Cornwall. The matter concluded with an inquest held on 9/10/19. Mr Bean was found to have died from: 1A) multidrug toxicity 2) chronic obstructive pulmonary disease. The conclusion recorded was that Mr Bean died by suicide. CIRCUMSTANCES OF THE DEATH Mr Bean had become agitated and distressed at his home address on the date of his death. He had telephoned his father who lived in Nottingham and to whom he had not spoken for two years. He told his father that he had failed him as a parent and that he was dying from an overdose of morphine (Oramorph) he had taken which was prescribed to him. His father rang East Midlands Ambulance Service to request an ambulance for his son in Cornwall. In error, the ambulance was directed to his father’s address in Nottingham. It was accepted at inquest that this error was not causative of the death as paramedics and police were also called to the address in Cornwall. Nevertheless, it was felt that this was an error of such a fundamental nature that action should be taken to ensure deaths did not occur in the future from a similar oversight. Information Classification: CONFIDENTIAL 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 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. — An ambulance was wrongly dispatched to the address of Mr Bean’s father in Nottingham rather than to Mr Bean in Cornwall. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. | am aware that your organisation has already reviewed the circumstances in which this error occurred. | would be pleased to learn the steps you have taken to prevent this sort of error from happening again. Could you also please confirm whether those steps have been audited and found to be sufficient? YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9/12/19. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Professor and GP.) | 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. [DATE] [SIGNED BY¥/CORONER] 10.10.2019
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