Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0384, written 18 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Nov 2019 |
|---|---|
| Reference | 2019-0384 |
| Deceased | Emma Langley |
| Coroner | James Bennett |
| Coroner area | Birmimgham and Solihull |
| Category | Emergency services related deaths (2019 onwards) |
| 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: Anthony C Marsh, Chief Executive West Midlands Ambulance Service 1 CORONER I am James Bennett Area Coroner for Birmingham and Solihull. 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 02/08/2019 I commenced an investigation into the death of Emma Jayne Langley. The investigation concluded at the end of an inquest on 30th October 2019. The conclusion of the inquest was Natural Causes. 4 CIRCUMSTANCES OF THE DEATH On 30 April 2019 Emma was diagnosed by her GP with an ear infection. On 1 May she was at home and developed a headache and vomiting and her family telephoned the 111 service, which resulted in an ambulance attending at 16.22. A paramedic considered the ear infection as the likely source of the symptoms. Meningitis was not considered. Two sets of observations were undertaken alerting the paramedic that the NEWS2 scoring system required Emma to be taken to hospital. A third opportunity to take observations was missed. The Sepsis Tool was not used - had it been used, it would have raised an amber warning alerting the paramedic that Emma needed to be taken to hospital. The paramedic wanted Emma to go to hospital but did not fully convey the clinical findings in order that Emma and her family could make an informed decision. No Discharge Form was provided to Emma and her family. The WMAS Electronic Patient Record was summarised to Emma’s partner and he signed the ‘non- conveyance’ statement. He did not realise they were rejecting a recommendation that Emma needed to go to hospital. The ambulance left at approximately 18.09, having arranged for a Dr via the 111 service to telephone Emma. At approximately 21.26 Emma was found collapsed in bed by her family, who called 999 and commenced CPR. Paramedics arrived at 21.34 and commenced advanced life-saving treatment without success, and Emma was confirmed deceased at 22.02. Post-mortem tests revealed that Emma had developed Streptococcus pneumoniae which is recognised as having a very rapid progression rate. It is difficult to predict precisely how Emma would have responded to treatment had she been taken to hospital at approximately 18.00hrs, but it is unlikely treatment would have changed the outcome. The medical cause of death was determined to be:- 1a. acute meningitis 2. diabetes mellitus. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The deceased/her family were keen for her to be admitted to hospital. The paramedic asked the deceased’s partner to sign the ‘non-conveyance’ statement on his EPR tablet after summarising a 1 hour 45 minute attendance. The rejection of medical advice was diluted by other details. The deceased’s partner stated he did not appreciate what he was signing. He was distressed and emotional and the room had been busy with family members, the paramedics and his ill partner. In my judgment, the facts of this case demonstrate the current system of signing a screen on a tablet after a generic summary, does not adequately amplify to a patient/their family (who might be distressed and emotional) they are rejecting medical advice to be admitted to hospital. 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. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13/01/20. 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 and the family. I have also sent it to NHS England who may find it useful or of interest. 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 18/11/2019 Signature James Bennett Area Coroner Birmingham and Solihull
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.
Ambulance Service Headquarters Waterfront Way Brierley Hill West Midlands DY5 1LX Tel: 01384 215555 website: www.wmas.nhs.uk Our Ref: 129768 Emma Langley Your Ref: COR 3288 28 November 2019 Mr James Bennett Area Coroner - Birmingham and Solihull 50 Newton Street Birmingham West Midlands B4 6NE Dear Mr Bennett Re: Regulation 28 Report to Prevent Future Deaths – Emma Langley (Deceased) Thank you for your email attaching the report to prevent future deaths. Please find our response below. Matter of concern - The deceased/her family were keen for her to be admitted to hospital. The paramedic asked the deceased’s partner to sign the ‘non-conveyance’ statement on his EPR tablet after summarising a 1 hour 45-minute attendance. The rejection of medical advice was diluted by other details. The deceased’s partner stated he did not appreciate what he was signing. He was distressed and emotional and the room had been busy with family members, the paramedics and his ill partner. In my judgment, the facts of this case demonstrate the current system of signing a screen on a tablet after a generic summary, does not adequately amplify to a patient/their family (who might be distressed and emotional) they are rejecting medical advice to be admitted to hospital. Response – We are currently in the process of changing the software on our electronic patient report to include a statement that will be visible on the screen where patients, family or carers will see and read prior to signing. This statement clearly sets out that they are signing to acknowledge the refusal for treatment and/or transport to hospital and/or referral for further care against the advice of the attending ambulance clinicians. It also goes on to state that the risks of this has been explained to them by the attending clinicians and they understand those risks. A review of the Trusts policy has also been undertaken in relation to the refusal of a patient to receive care and changes have been made to provide clarity to all our clinicians over the expectations on them where a patient declines treatment. Changes have also been made to the patient discharge advice leaflet which will provide clearer advice and guidance to patients who are left on scene following our attendance. Can I please take this opportunity to pass on my sincere condolences to the family of Ms Langley. I hope this provides you with the appropriate level of assurance that WMAS has dealt with the issues highlighted within the report to prevent future deaths. If you require any further information, please do not hesitate contact me. Yours Sincerely Professor Anthony C. Marsh Chief Executive Officer
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