Samantha Brousas

Date of report	20 Dec 2019
Reference	2019-0443
Deceased	Samantha Brousas
Coroner	Joanna Lees
Coroner area	North Wales (East and Central)
Category	Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (2019 onwards)
Organisation named	Welsh Ambulance Services NHS Trust
Source	judiciary.uk record · original PDF
Responses published	1

The report

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

THIS REPORT IS BEING SENT TO:

1.Welsh Ambulance Services NHS Trust, HM Stanley Site, St Asaph, Denbighshire LL17
ORS

CORONER

lam Mrs Joanne Lees, Assistant Coroner, for the coroner area of North Wales (East &
Central).

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 1/3/18 | commenced an investigation into the death of Samantha Brousas who died
on the 23° February 2018 at Wrexham Maelor hospital. The investigation concluded
at the end of the inquest on 20/12/19. The Coroners conclusion was a narrative
conclusion.

CIRCUMSTANCES OF THE DEATH

The deceased became ill in the winter of 2018. She visited her gp practice twice before
consulting with her gp on 20/2/18 with symptoms of diarrhoea and vomiting and was
diagnosed with gastric flu. By the following day she had significantly deteriorated with a
high temperature and difficulty slowing her breathing down. An ambulance was called
at 15:33 arriving at her home address at 16:45 by which time she had a NEWS score of
13, suspected sepsis and was critically ill. There was no pre alert to the hospital. The
ambulance arrived at the ED at 17:29 and the deceased was held outside receiving
fluids, oxygen and paracetamol without being triaged. She was admitted into the ED at
19:40. The ED was in escalation and operating at the highest level of extreme pressure.
Within an hour of being admitted into the ED the deceased received antibiotics and
supportive care having been diagnosed with septic shock secondary to pneumonia.
Sadly, she failed to respond to treatment, she deteriorated and passed away on
23/2/19 from a naturally occurring infection.

| concluded that none of the above facts affected the outcome.

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. —
(1) During the course of the inquest | heard evidence that the two paramedics who

attended the home address of the deceased identified her as having a NEWS score of 13
with suspected sepsis. Both paramedics made a joint decision not to pre alert the

emergency department at Wrexham Maelor hospital whilst being aware that there were
already ambulances waiting outside the emergency department. | heard evidence that
this was against the Joint Royal Colleges Ambulance Liaison Committee (JLARC) clinical
guidelines that if sepsis is identified an alert SHOULD be made. At that time the Welsh
Ambulance Service Trust (WAST) had in effect a Clinical Notice regarding the use of the
ASCHICE mnemonic but not the circumstances under which it was to be used creating
room for discretion to be exercised. It was accepted as part of a WAST investigation that
a pre- alert should have been used. My finding on the evidence was that ‘the absence of
a pre alert meant that the ED had no opportunity to prepare for Sam’s arrival and there
could have then been no doubt as to the severity of her illness or her condition’ and ‘it
would least have had the effect of alerting the department that a critically unwell patient

was on their way and enabling them to make efforts to find or make a bed for (the
deceased).

To be clear my finding was that the absence of a pre alert did not affect the outcome.

| heard evidence that in December 2018 WAST issued a further clinical notice clarifying
the expectations for the use of the pre alert but this fell short of a mandatory
requirement for a pre alert for suspected sepsis.

My concern is that this creates a discretion which is not compatible with the JLARC
guidelines and may result in a similar situation where a pre alert is not used in a life
threatening time critical situation as happened with the deceased, which may present a
tisk to life.

(2) | heard evidence during the course of the inquest that the first line treatment for
sepsis was the administration of anti-biotics within an hour of arrival at a hospital
consistent with the SEPSIS SIX and NICE guidelines. | also heard evidence that it was
currently beyond the scope of the practice of WAST paramedics to administer antibiotics
intravenously in an ambulance. Given the importance of the role of the Paramedic in the
early diagnosis of Sepsis my concern is that when a patient is unable to be admitted into
the emergency department in similar situations as the deceased, the absence of the
administration of antibiotics increases the mortality risk of such patients which could be
addressed by exemptions and local organisational level policies and procedures.

(3) During the course of the inquest | heard evidence that both paramedics attending the
deceased had significant concerns about both the patient’s condition and the delay in
admission into the ED. Despite these concerns, neither paramedic escalated these
concerns either through Ambulance Control or through hospital escalation channels
(which were known to Ambulance Control). My concern is that there was an absence of
a policy or procedure whereby staff could escalate such concerns thereby missing an
opportunity to highlight individual cases requiring immediate escalation in the absence
of any clear management plan for the patient’s admission.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14/2/20. |, 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 report to the Chief Coroner, ing Interested
— | University Health Board and partner of the
deceased.

lam 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.

M ne M. Lees
Assistant Coroner

North Wales (East & Central)
20/12/19

Responses

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.

Response from The Welsh Ambulance Services (PDF)

Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol 
Regional Ambulance Headquarters and Clinical Contact Centre 
Tŷ Vantage Point / Vantage Point House, Tŷ Coch Way, Cwmbran NP44 7HF 
Tel/Ffôn 01633 626262      Fax/Ffacs 01633 626299 
www.ambulance.wales.nhs.uk 

CHAIR AND CHIEF EXECUTIVE’S OFFICE  

Ein Cyf/Our Ref:  JK/5260 

10 February 2020 

PRIVATE AND CONFIDENTIAL  
Mrs J M Lees 
Assistant Coroner 
H M Coroner’s  
County Hall 
Wynnstay Road 
Ruthin 
Denbighshire 
LL16 1YN 

Dear Mrs Lees 

Inquest relating to Ms Samantha Brousas 

I am writing in response to the Regulation 28 that you issued to the Welsh Ambulance 
Services NHS Trust (the Trust) dated 20 December 2019, following the sad death of 
Ms Samantha Brousas in February 2018.  In the report you raised concerns in relation 
to three matters. 

Coroner Concern 1 – Absence of a pre-alert 

At  the  time  that  the  incident  occurred,  the  Trust  did  not  have  pre-alert  guidance  in 
place.    This  was  rectified  in  December  2018.    The  guidance  was  developed  in 
conjunction  with  the  Clinical  Directors  from  each  Health  Board  Area  in  Wales  and 
Royal College of Emergency Medicine Wales. [ref Clinical Notice 16/2018] 

The  2017  Joint  Royal  Colleges  Ambulance  Liaison  Committee  (JRCALC) 
Supplementary Guidelines stated a pre-alert should be given for suspected sepsis, a 
message that was further reinforced on the Trust’s pre-alert guidance.  In addition, the 
updated 2017 sepsis guidelines were covered during the 2018/19 mandatory training 

Prif Weithredwr/Chief Executive: Jason Killens 
Mae’r Ymddiriedoloeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg 
The Trust welcomes correspondence in Welsh or English 

 Cadeirydd/Chair :  Martin Woodford              

                                                                
 
 
 
 
 
 
 
 
       
 
 
             
 
                                                                                                                                                 
 
 
 
 
 
 
 
 
 cycle  with  the  importance  of  the  pre-alert  message  being  further  advocated  to  all 
emergency medical services staff through an agreed national education session.  The 
session enabled crews to be able to identify the red flags for sepsis whereby a pre-
alert would be expected. 

The pre-alert guidance, as well as the mandatory training session, served to reinforce 
the  key  role  the  Trust’s  crews  have  in  identifying  and  then  informing  the  hospital 
through  the  pre-alert  that  they  suspect  sepsis  for  a  given  patient.    Nevertheless, 
JRCALC is itself a guideline, not a policy, and is not designed to be everything to every 
patient  but  a  readily  applicable  framework  to  assist  in  clinical  decision-making. 
JRCALC will frequently, in the text, refer the reader to local processes where required 
within their guidance. 

The 2019 JRCALC is accessible to crews either through Trust provided subscription 
to the JRCALC Plus App, available on a personal smartphone or tablet device.  Trust 
crews who did not opt for the App were issued with the 2019 pocketbook.  

It would not be feasible to create a policy which dictated all circumstances in which a 
pre-alert is needed as, by logical extension, doing so would also create a (longer) list 
of conditions that do not require pre-alert. 

For example, a patient’s pre-existing condition may mean that what is considered as 
“normal” for them would result in a high National Early Warning Score (NEWS).  As 
such,  elevated  NEWS  in  these  circumstances  would  warrant  the  crew  to  make  a 
discretionary  decision  regarding  the  pre-alert.    Nevertheless,  we  would  expect  that 
crew to explain the rationale for their decision in the narrative section of the Patient 
Care Record.  Therefore, mandatory pre-alert policies are not recommended on the 
grounds  of  complexity,  and  that  it  would  not  be  possible  to  write  an  exhaustive  list 
which is applicable in all circumstances. 

Coroner Concern 2 – paramedic administration of anti-biotics 

The Trust recognises the importance of the role of the paramedic to identify sepsis, 
initiate  treatment  and  pre-alert  to  the  Emergency  Department,  as  evidenced  by  the 
reference  in  the  pre-alert  guidance  and  the  continuous  professional  development 
(CPD) training.  The administration of antibiotics by paramedics in sepsis has been 
subject to a small number of studies, when findings may affect our current practice.   

East Midlands Ambulance Service undertook a feasibility study to determine whether 
paramedics could appropriately deliver an antibiotic to ‘red flag’ sepsis patients and 
calculate  the  blood  culture  contamination  rate  when  blood  was  drawn  in  the  pre-
hospital environment by paramedics.  Twenty paramedics took part in the study.  The 
results  indicated  that  paramedics  could  safely  deliver  pre-hospital  antibiotics  to 
patients with ‘red flag’ sepsis and obtain blood cultures prior to administration, with a 
contamination rate comparable with local hospitals, following a short training course.  

2 

 
 [Ref  Chippendale  J.  et  al  2018.  The  feasibility  of  Paramedics  delivering  antibiotic 
treatment  pre-hospital  to  ‘red  flag’  sepsis  patients:  a  service  evaluation.  British 
Paramedic 
2, 
https://www.ingentaconnect.com/content/tcop/bpj/2018/00000002/00000004/art0000
3?crawler=true] 

Volume 

Journal 

pages 

Issue 

4, 

19-24   

The  PhRASe  (Prehospital  Recognition  and  Antibiotics  for  999  patients  with  severe 
Sepsis)  study  was  designed  to  determine  if  it  was  feasible  for  Trust  paramedics  to 
select and screen eligible patients, then randomise them to usual care or intervention 
(blood culture collection and administration of IV antibiotics).  The main purpose of the 
study was to gather evidence, to inform the feasibility of a definitive study that could 
examine the effectiveness of prehospital antibiotics.  This study is in the final stages 
of data analysis of anonymised follow-up via the SAIL databank.  

[ref Moore C., et al 2018, Prehospital recognition and antibiotics for 999 patients with 
Sepsis:  protocol 
feasibility  study  Pilot  and  Feasibility  Studies  4:64 
https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-018-0258-8] 

for  a 

The large scale PHANTASi Trial indicated that the early administration of antibiotics 
for patients with Sepsis by paramedics in Holland did not lead to improved survival, 
regardless  of  illness  severity,  but  training  prehospital  staff  did  improve  early 
recognition and care in the whole acute care chain.  In this study, the median time for 
receiving  antibiotics  was  26  minutes  prior  to  Emergency  Department  arrival  for  the 
intervention group.  For the control group, the median time for antibiotic administration 
was 70 minutes after arrival at the Emergency Department, compared with 93 minutes 
before training of the prehospital personnel. 

The key message from this study is that education and providing usual care (oxygen 
and fluid therapy) are central to improving early recognition and care, rather than the 
timing of the antibiotics.   

[Ref:  Alam  N,  et  al.  2018,  Prehospital  antibiotics  in  the  ambulance  for  sepsis:  a 
multicentre,  open  label,  randomised  trial.  Lancet  Respiratory  Medicine  Volume  6, 
2018 
ISSUE 
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(17)30469-1/fulltext] 

January 

P40-50, 

01, 

1, 

Therefore, the current evidence base is not strong enough to demonstrate the benefits 
of  out-of-hospital administration  of  antibiotics  in  sepsis  by  all  paramedics,  including 
time  taken  to  train,  the  costs  involved  to  purchase  the  additional  medications  and 
equipment, and maintain competency in the use of the drugs.  In addition, controlled 
use of antibiotics is considered best practice to prevent antimicrobial resistance, which 
is on the increase. 

The  Trust  advocates  that  any  administration  of  antibiotics  for  patients  with  red  flag 
sepsis should be initiated within the Emergency Department and not in the back of an 
Emergency Ambulance.  For patients held in the back of ambulances due to excessive 

3 

 
 delays  who  require  antibiotic  treatment,  this  can  be  initiated  by  Health  Board 
Emergency Department staff who are qualified to prescribe the medication, can select 
the  most  appropriate  antibiotic  to  use  depending  on  local  patterns  of  antibiotic 
resistance and can collect the necessary blood specimen for cultures.  

Coroner Concern 3 – escalation of concerns when delayed at hospital. 

Patients  in  the  Emergency  Department  or  held  in  the  back  of  the  Emergency 
Ambulance on the forecourt are recognised in the 2016 Welsh Health Circular as the 
responsibility of the Health Board.  As such, at all times, Trust crews should be able 
to  escalate  any  clinical  concerns  directly  to  the  Emergency  Department  via  the 
ambulance  triage  nurse,  nurse  in  charge  or  other  senior  clinician  and  reasonably 
expect  action to  be  taken.    Given  the findings  of  the  inquest,  the Trust are  actively 
designing an agreed escalation process that crews can use on the occasions that their 
concerns are not felt to be acted upon by staff in the Emergency Department. 

I would like to extend my sincere condolences to the family of Ms Brousas on their sad 
loss.  I would also like to extend the offer to meet with you to discuss our response in 
more detail and to provide you with any further assurance you may require regarding 
our commitment to continuous improvement to support the prevention of future deaths.   

Yours sincerely 

Dr Brendan Lloyd 
Executive Medical Director 

Encs: Clinical Notice 16/2018 

Action plan 

4

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