Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0019, written 31 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 | 31 Jan 2020 |
|---|---|
| Reference | 2020-0019 |
| Deceased | Ashley Walker |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive – West Midlands Ambulance Service 1 CORONER I am S McGovern, senior coroner, for the coroner area of Warwickshire. 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 19 August 2019 I commenced an investigation into the death of, Ashley WALKER, 25 years old. The investigation concluded at the end of the inquest on 30 January 2020. The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH On 17 August 2019, Mr Walker telephoned West Midland Ambulance Service (WMAS) and informed them he had ingested to his property and arrived at 1324. On arrival Mr Walker’s Glasgow Coma Score was 3 which increased to 6 after the administration of oxygen. The crew continued to treat Mr Walker until 1345 when they were directed to leave as the scene was said to be hazardous to their health. The scene was not hazardous and there was no requirement for the crew to leave. Mr Walker was left unattended for 45 minutes until the fire crew extricated him from the building. He was not breathing when he was extricated. I heard evidence that he had ‘ a real chance of survival’ had the crew not left. . An ambulance crew was dispatched 5 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) It is apparent that a communication error confused the ingestion of with a spillage of . (2) toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as Chief Executive of the WMAS 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 27 March 2020. 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 to the following Interested Persons – (a) Family of Mr Walker (via his mother ) 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 31 January 2020 Senior Coroner S McGovern
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.
Your Ref: 01062-2019 Our Ref: COR 3383 Mr S McGovern Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL 21 February 2020 Dear Mr McGovern Re: Regulation 28 Report to Prevent Future Deaths - Ashley Walker (Deceased) Thank you for your email dated 4 February 2020 attaching your Regulation 28 Report. Please see our response to your concerns below: Concern 1 It is apparent that a communication error confused the ingestion of sodium nitrate with a spillage of sodium nitrate. Response Following this incident we have instructed all of our staff to remove the WISER (Wireless Informaton System for Emergency Responders) App from all work mobile phones and tablets. The App will now only be used following training by Tactical Incident Commandars (TICs), the National Inter-Agency Liaison Officer (NILO) and team leaders in our Hazardous Area Response Team (HART). This is to ensure the risk of harm to both our patients and staff is reduced and to mitigate confusion at scene, as crews on scene will only be able to access advice from trained officers. As a Trust we have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents which highlight the clinical management differences between individual ingestion and chemical spills for all of our Officers. Concern 2 Sodium nitrate toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance. Response We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally. Can I please take this opportunity to pass on my sincere condolences to the family of Mr Walker. I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report. If you require any further assistance, please do not hesitate contact me. Yours sincerely Professor Anthony C. Marsh Chief Executive Officer
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