Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0107, written 27 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 | 27 Jan 2020 |
|---|---|
| Reference | 2020-0107 |
| Deceased | Helen Sheath |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Emergency Services related deaths · Mental Health related deaths · Other related deaths |
| Organisation named | East London NHS Foundation Trust · East of England Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
47769-2019 Senior Coroner - Emma Whitting Bedfordshire & Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Emergency Call Prioritisation Advisory Group (ECPAG), Association of Ambulance Chief Executives, National Association of Ambulance Medical Directors 1 CORONER I am Emma WHITTING, Senior Coroner for the area of Bedfordshire and Luton Coroner Service 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On Twenty-Eighth July 2019 I commenced an Investigation into the death of Helen Jayne SHEATH aged 33. The investigation concluded at the end of the inquest on Tenth December 2019. The conclusion of the inquest was a Narrative Conclusion :The Deceased died from a fatal dose of sodium nitrate; although this was procured by the Deceased and self-administered, her intentions in doing so were unclear. The medical cause of death was: Ia Fatal Methemoglobinemia Ib Ingestion of Sodium Nitrate II Excess use of Fluoxetine 4 CIRCUMSTANCES OF THE DEATH The Deceased had a recent history of self-harm and suicidal ideation which had resulted in several in-patient psychiatric admissions. Following her discharge from the last admission in Townsend Court on 3 July 2019 she was still awaiting an Out-Patient Appointment with psychological assessment and treatment from the Community Mental Health Team when, whilst at home, she ingested a fatal dose of sodium nitrate at around 6.30pm on 20 August 2018. Paramedics were first called at 6.20pm and attended to her at 7.05pm; however, soon after their arrival, she became acutely unwell. She was admitted to Bedford Hospital but, despite treatment, her death was confirmed there at 8.25pm. Although the Community Mental Health Team had been alerted to her threats to harm herself and had attended her home earlier that ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> afternoon they had left before being able to gain access even though a family member was due to attend later with a key. Although their continued presence at the property would not necessarily have avoided the fatal outcome it could potentially have done so. 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) Helen’s father first called ambulance services at 18.20 hours on 2018 which was before she had ingested the sodium nitrate. EEAS’s investigation report stated that “from the information provided on this call, that Helen had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled “Psychiatric/Abnormal Behaviour/Suicide Attempt” and the call was coded as a Category 3. This call has been audited by the Quality Assurance Team and was correctly coded and the correct set of questions used” ….yet a Category 3 call is for patients who have potentially urgent conditions that are not life threatening and yet Helen had a history of suicide ideation and her father was unable to tell, being the other side of the locked door, whether the substance had been taken or not. In view of both Helen’s past medical history and the fact that her father had no knowledge as to whether the substance had been ingested or not at that stage, it seemed to the Court that an assumption that an overdose had been taken ought to have been made and this first call, therefore, coded as a Category 2; (2) Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call and it was only after a second call was made to ambulance services at 18.48 hours, when the call handler selected the set of questions titled “Overdose/Poisoning/Ingestion” because it was said that it was suggested on this call that she had ingested the substance that the call was coded a Category 2 and that, due to the lack of DSA availability, at 18.57 hours a Rapid Response Vehicle (RRV) was dispatched with the Mental Health Street Triage Team who arrived at 19.05 and 19.11 hours respectively with a different DSA arriving at 19.25 hours. (3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you «Contactfullname» have the power to take such action. 6 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 March 2020. I, the Coroner, may extend the period. Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX 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: East of England Ambulance Service NHS Trust, brother) and East London NHS Foundation Trust. (Deceased’s 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 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Dated: 27 January 2020 Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX
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.
18 June 2020 BY EMAIL Senior Coroner - Emma Whitting Bedfordshire & Luton Association of Ambulance Chief Executives T: E: @aace.org.uk W: www.aace.org.uk Dear Ms Whitting REGULATION 28: HELEN SHEATH I am writing in response to the Regulation 28 report to prevent future deaths following the inquest into the death of Helen Sheath which you issued on 29th April 2020 to the Association of Ambulance Chief Executives (AACE), National Ambulance Service Medical Directors (NASMeD) and Emergency Call Prioritisation Advisory Group (ECPAG). AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service however we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. One of our specialist sub groups is the National Ambulance Service Medical Directors (NASMeD) and this response therefore is from AACE and has been informed by NASMeD. The response categories are set by the Emergency Call Prioritisation Advisory Group (ECPAG), an NHS England led group responsible for the governance, control and approval of any change to clinical code sets (aligning codes to response categories). When 999 is called, the call is assessed by using a triage tool. East of England Ambulance Service and four other ambulance trusts in England use AMPDS and the other five trusts use NHS pathways. The 999 call taking staff are trained to use these systems and follow a set of questions that relates to the information that is given to them over the telephone and they have to follow a defined process which then determines the category of response. This ensures that all calls are appropriately categorised so that patients with life threatening conditions receive the most appropriate and timely response. This does sometimes mean that an ambulance has to be diverted from a lower to a higher priority call. NASMeD are supportive of a letter that was sent to ambulance trusts in April 2019 from Professor at NHS England to: , the then National Clinical Director for Urgent and Emergency Care “ensure they have robust clinical oversight in place in control rooms to monitor self-harm and suicidal patients safely and effectively, particularly those who have been allocated a Category 3 or 4 response initially”. Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE And stated that: “consideration should be given, at the point of call, to the type of overdose and quantity taken (where relevant), and to the intent to end life, all of which will determine the necessary response including the need to upgrade a call for clinical reasons...". A person that is threatening suicide does not constitute a life-threatening emergency and therefore doesn’t warrant a higher category of response but, given the potential for a small number of these cases to become potentially life threatening, early clinical review of these calls is recommended. NASMeD has previously encouraged all ambulance trusts to implement clinical review of these cases in support of the letter sent by Professor 2019. in April 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 in order 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 the family of Helen Sheath. Yours sincerely Martin Flaherty OBE Managing Director Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
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