Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0015, written 20 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2020 |
|---|---|
| Reference | 2020-0015 |
| Deceased | Aston McLean |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Emergency services related deaths (2019 onwards) · Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Classification: OFFICIAL-SENSITIVE
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
i 4. JRCALC
| AACE, GG322, Metal Sox Factory, 30 Great Gulléford St,
London SE1 OHS, and also by email.
“GGRONER |
i
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Lam Heidi J Connor, senior coroner, for the coroner area of Berkshire.
ORONER’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 2073, \
“VINVESTIGATION and INQUEST
| conducted an inquest into the death of Aston Neil McLean that was heard by a jury at |
Reading Town Hall from 11-22 November 2019. The jury concluded that the timing of
_ the decision by arnbulance staff to declare Aston deceased on scene did not cause or |
_ contribute to his death.
|
| CIRCUMSTANCES OF THE DEATH
_ The family asked us to refer to the deceased as Aston at the inquest. | have refiected
_ that request in this report. |
In the early hours of 6 August 2014, Aston was pursued by Thames Valley Police from |
_ the scene of a suspected offence. Tragically, this resulted in a collision with an armed
“response vehicle at 01.56 hours thai morning, Aston was trapped underneath the
| could see his head sticking out from under the vehicle. He was not able to assess
Aston’s airway. He could not see or hear any breathing. He was not able to feel a pulse |
_yehicle. An ambulance technician attended at 01.59 hours. When he got fo Aston, he |
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i on Aston’s wrist. He was not able to detect any neurological response or signs of life.
i |
|
He concluded that Aston was dead. Aston was declared deceased at 02.05 hours.
| Subsequent te this, it was agreed that there was no way to lift the heavy armed
response vehicie In a safe manner. The evidence of the embulance crew was that they |
did not know how long it would take for the fire service to attend, nor how jong it wouid
take them to lift the vehicle off Aston.
|
The ambulance crew who attended belleved Aston had injuries incompatible with |e. |
They assumed Aston had been under the vehicle for longer than he in fact had. it was |
thought that Aston had suffered an injury which was “unequivocally associated with |
death” ~ because of the car crushing down on him. When completing the Recognition of
| Life Extinet form (ROLE’), the crew felt that the relevant category was that of "massive i
| similar injuries”. i
|
| Subsequent evidence from the fire service (together with reconstruction videos) |
| indicated that the fire service was likely to have been able to lift the vehicle off Aston |
| within 4% minutes. They were in attendance at the scene from 02.04. |
| instructed an independent expert in this case. He is an ICU consultant who has
| previously been the Clinical Director of an ambulance service and is also involved in|
'raviewing JRCALC guidelines. The expert gave evidence that he too would have
| declared Aston deceased in the way that the attending crew did. He aiso however |
“indicated that, if the vehicle had been lifted off Aston very soon after the collision, he
_____ may have survived. This aspect of his evidence is arguably contradictory, given that_
i
Classification: OF PICIAL-SENSTTIVE
Classification: OFFICIAL-SENSITIVE
ecogniti i ! here there is a
_ condition ° “anedui ivocal ily associ ciated with death”.
both the attending crew and the oe have taken it into woo (correctly y OF “otherwise)
view that the vehicle could not be lifted off Aston soon enough to change the outcome.
CORONER'S CONCERNS
uring the course of the Inquest the evidence revealed matters giving rise to concern. In
| i ae opinion there is a risk that future deaths could occur unless action is taken, In the /
: circumstances itis my statutory duty to report to you. :
The MATTERS OF CONCERN are as follows. ~ |
(4) | invite you to reconsider your guidelines in relation to ROLE, to clarify that this |
should only occur where death has already taken place, and not on the basis of
' either of the following assumptions:
| (a) Likely death at some imminent point in the future: and/or
: (b) Perceived difficulty in the timing of extracting a patient from a position where |
! providing treatment is physically impossible
in this case, the decision not to if the vehicle was based on a declaration of
death in circumstances where the ambulance crew had no knowledge of how |
quickly the fire service would be able to lift the vehicle off Aston. Whilst the jury
found that this did not cause or contribute to Aston’s death, there is @ risk of.
future deaths should a similar scenario occur.
: (2) The need for a wider category of Injuries “unequivocally associated with death’
i iLe. “massive similar injuries’) makes sense, given that no list could possibly
| i include every scenario. The current guidance makes clear that any condition |
i | this category must be ‘ ‘unequivocal ly associated with death’. In addiflon, the
/ phrase “similar massive injuries” is in the same category as “hemicorporectomy”. _
it may be that the inference from thi 5 is already sufficiently clear, but it may also |
be useful for you to consider making clear whai level of injury is covered by th
phrase “similar massive injuries’. There should presumably be no doubt
whatsoever that death has occurred.
/
(3) It was clear from the evidence in this case that the crew attending did not know
\ that the fire service had equipment which would have enabled them to ift the
/ vehicie off Aston within a short space of time. This could clearly form an |
| important part of key decision making at scenes like this. | invite you to consider |
: incorporating within your guidelines the recommendation that local ambulance
/ services should obtain relevant information from their local fire service on this
| | point, and include this in local guidance.
8 ACTION SHOULD BE TAKEN
Fin my opinion action should be taken to prevent future deaths and | believe your |
| organisat on has the power fo take sucn action.
|
7 | (7 | YOUR RESPONSE _
i
{
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| You are under a duty to respond to this report within 56 days of the date of this report,
i | namely by 16 March 2020. |, the coroner, may extend this 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 ne action is proposed, |
i
| of |
“2 SGPIES and PUBLICATION _ i
“| have sent a copy of my report to the Chief Coroner anc aiso to the legal |
2
Classification: OFFICIAL-SENSITIVE
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}
| repres
(4) South Central Ambulance Service.
(2) Royal Berkshire Fire and Resc
ue Service
Asion’s former pariner, :
| of this report to the f llowing organisations ivia their legal representatives where these
| are known):
| Lam also under a duty to send the Chief Coroner a copy of your response.
i
i
The Chief Coroner may publish either
1b a copy
or both in a cornplete or redacted or summary | |
| form. He may send a copy of this report to ary person who he belleves may find useful |
or of interest. You may make representatio’
| response, about the release or the publication of your response by the Chief Coroner.
ssification: OFFICIAL-SENSITIVE
SIGNED BY CORONER
ng to me, the coroner, at the time of your
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.
Association of Ambulance Chief Executives Metal Box Factory (GG322) 30 Great Guildford Street London SE1 0HS E: T: 020 7118 0977 W: www.aace.org.uk 3 March 2020 BY EMAIL: Mrs Heidi Connor Senior Coroner for Berkshire Dear Mrs Connor REGULATION 28 REPORT: ACTION TO PREVENT FUTURE DEATHS: ASTON NEIL MCLEAN We are writing further to your Regulation 28 report to prevent future deaths which you issued following the inquest into the death of Aston Neil McLean, and sent by e mail to JRCALC on 21st January 2020. Firstly, may we clarify the roles of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the Association of Ambulance Chief Executives (AACE) and the National Ambulance Services Medical Directors group (NASMeD). JRCALC is a group of medical specialty experts and its role is to provide robust expert clinical advice on the instruction of AACE and its advisors, NASMeD. AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts which are all full voting members. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Its primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. The responsibility for standards of clinical care within Ambulance Trusts rests with the Chief Executives and Medical Directors of each ambulance service. On behalf of AACE, NASMeD provides clinical assurance and leads the development of future versions of the clinical guidelines. With regards to your matters of concern, we are reviewing the current JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). We will be amending and adding wording to clarify what to do in circumstances where access to the patient is not possible, such as when trapped under a vehicle or in an inaccessible position. We will be clarifying the need to work with other agencies such as the fire and police services, to support the decisions made with regard to rescue and considering factors such as the safety and risks to the rescue teams. Once these changes have been approved, we will issue them onto the JRCALC App. This is the platform for ambulance clinicians to access the latest and most up to date clinical guidelines. Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE I hope that you will agree that we have responded to the concerns that you have raised. We can assure you that we are absolutely committed to learning from all adverse events and doing everything within our power to prevent them happening again in the future. If we may be of further assistance, please do not hesitate to contact us. We would like to extend our sincere condolences to Aston’s family. Yours sincerely Martin Flaherty OBE Managing Director, AACE Dr Julian Mark Chair, NASMeD cc: Dr Alison Walker, Chair, JRCALC Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
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