Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0138, written 1 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2020 |
|---|---|
| Reference | 2020-0138 |
| Deceased | Joan McIndoe |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Emergency Services related deaths · Other related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health 1 CORONER . I am Alison Mutch Senior Coroner, for the coroner area of South Manchester 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 16th September 2019 I commenced an investigation into the death of Joan Margaret Mcindoe. The investigation concluded on the 22nd June 2020 and the conclusion was one of Natural Causes. The medical cause of death was 1a) Acute left ventricular failure; 1b) lschaemic heart disease; 1c) Coronary artery atheroma 4 CIRCUMSTANCES OF THE DEATH Joan Margaret Mcindoe resided at 33 Mayfair Court, a retirement complex. In office hours from Monday - Friday there was an on-site manager. Out of hours there was an alarm system in operation. On 14th September 2019 at 05:39 the alarm in her flat was activated. The call centre monitoring the alarm was unsuccessful in making contact with her and the Ambulance Service was contacted. The call was categorised as a category 4 call in accordance with national policy regarding calls of this type. There was no follow up by the call centre. Her family were notified of the activation and that an ambulance had been called. At about 07:30 her family attended and found her unresponsive in the shower. A further call was placed to NWAS who responded immediately. They pronounced her dead on their arrival after carrying out an assessment. l 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 MA TIERS OF CONCERN are as follows. - \ 1. The inquest was told that all such calls as this from residential facilities where contact cannot be established with the resident are automatically categorised as a Category 4 response by the ambulance service. This is in contrast to where a call is initiated and then contact is lost during the call. I I 2 . During the course of the inquest evidence was given that there is a lack of clarity about expectations for updates once a call has been placed by a call centre to the ambulance service. As a result there is no way of understanding if the position is evolving for example as in this case where the alarm kept going off and there was still no response from Mrs Mcindoe. I I I 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 26th August 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, namely Mr ~ deceased, who may find it useful or of in eres . on of the I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Alison Mutch OBE HM Senior Coroner 01.07.2020 .. 3
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.
ae From Edward Argar MP Department Minister of State for Health of Health & 39 Victoria Strest Social Care SW1H OEU - | 020 7210 4850 Your Ref: ill RA Our Ref: | aE | } Ms Alison Patricia Mutch HM Senior Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG ae V" December 2020 Dear Ms Mutch Thank you for your letter of 1 July 2020 to Matt Hancock about the death of Joan Margaret Mcindoe. | am replying as Minister with responsibility for ambulance services and | am grateful for the additional time in which to do so. First, | would like to offer my sincere condolences to the family and loved ones of Mrs MclIndoe. We must do all we can to take the learnings from the circumstances of Mrs McIndoe’s death to improve the safety of others. Your report raises two matters of concern relating to interaction between telecare monitoring agencies and ambulance services and my officials have sought the advice of the Association of Ambulance Chief Executives (the AACE); NHS England and NHS Improvement (NHSEI); and the Care Quality Commission (CQC) in preparing this response. The AACE provides central support and co-ordination to ambulance services to assist with implementation of national policy and the improvement of patient care. Although the AACE is not constituted to mandate or instruct ambulance services, it facilitates and enables the development of good practice. This includes consideration of concerns identified by coroners, where the AACE’s National Ambulance Medical Directors Group will discuss and disseminate learning from Prevention of Future Deaths reports. The concerns in your report have been brought to the attention of the AACE. In relation to the categorisation of calls from alarm monitoring agencies by ambulance services, where contact with a resident has not been established, | am advised by the AACE that the Advanced Medical Priority Dispatch System (AMPDS), an internationally recognised system that is used by around half of all ambulance services in the country including the North West Ambulance Service (NWAS), this type of call is mapped to Category 5. This means that calls of this nature should automatically receive an initial clinical assessment so that an ambulance clinician can assess the call and attempt to obtain information to establish the type of response that is required. This might include but is not limited to upgrading the incident for an expedited face to face assessment or conducting further telephone triage. Similarly, | am advised that NHS Pathways allows for a call handler to transfer the call to a clinician for further assessment and risk management. There might also be local operational procedures in place to support the management of alarm calls by ambulance services. [am not able to comment on the specifics of this case. However, as with all serious incidents, | expect the North West Ambulance Service to reflect carefully on the circumstances of Mrs McIndoe's death and the findings of your investigation and to identify and take forward any actions for improvement. In relation to the second matter of concern about clarifying the expectations of telecare monitoring agencies to provide updates to the ambulance service to aid understanding of how incidents are evolving, it is key that alarm monitoring agencies gather as much information as possible about the alarm call to help ambulance services determine if an ambulance response is required (and the category of the response) or if a local response is more appropriate. | am advised that the AACE has identified a need for greater clarity and consistency around the interaction between telecare monitoring agencies and ambulance services and the AACE is engaging with the Technology Enabied Care Services Association (TSA), a membership organisation for technology enabled care providers, on these matters with the aim of influencing how telecare providers engage with ambulance services. The AACE will bring the circumstances of Mrs McIndoe's death and the concerns you have raised to the attention of the TSA to inform these discussions. In addition, | am advised that the AACE is encouraging ambulance services to collect data on the type and numbers of calls they receive from telecare monitoring agencies to further support consideration of these matters. You may also wish to note that northern ambulance services are supporting work to explore how a decision support too! could assist telecare monitoring agencies to decide when to transfer calls to the ambulance service (and the type of information required by ambulance services to determine the category of response), or other locally agreed pathways of care. | hope this provides assurance that action is being taken to improve and strengthen the interaction between ambulance services and telecare monitoring agencies. In addition, NHSEl is in regular and close contact with the AACE, where concerns such as the interaction between ambulance services and alarm monitoring agencies continue to be discussed. Technology enabled care providers play a vital role in supporting the independence, health and safety of older and vulnerable people and in doing so, it is essential that they can demonstrate the quality and safety of the service they operate. One way to do this is for telecare providers to apply to become certified against the Quality Standards Framework’, overseen by TEC Quality, which has recently been accredited by the UK Accreditation Service (UKAS). The Quality Standards Framework sets out ten quality standards and four service delivery modules, together with key outcomes, against which providers are audited. This includes a delivery module specifically for telecare monitoring that outlines minimum expectations. For example, a locally agreed process for passing calls to the emergency services and monitoring a service user's welfare when a call has been passed to a responder such as the ambulance service?. Commissioners of telecare services have influence when agreeing contracts in setting expectations of quality and safety. For example, by specifying that providers have received accreditation against a framework of standards. Given the significant role of local authorities in contracting with telecare providers, | have asked my officials to bring your concerns to the attention of the Association of Directors of Adult Social Services (ADASS) to raise awareness of these matters and the benefits of contracting with organisations certified by standard bodies, such as TEC Quality. | hope this response is helpful. Thank you for bringing these concerns to my attention. ye Ca) ' a Aes EDWARD ARGAR MP 1 https:/Avww.tecquality.org.uk/the-asf-modules 2 https://irp- cdn.multiscreensite.com/a9a7c1d1 ffiles/uploaded/A.%20Telecare%20Monitoring%20V3.3%2025th%20Febr uary%202019.pdf
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