Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0187, written 29 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2020 |
|---|---|
| Reference | 2020-0187 |
| Deceased | Sarah Ferneyhough |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Alcohol, drug and medication related deaths · Emergency Services related deaths |
| Organisation named | 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.
ANNEX A 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: Emergency Call Prioritisation Advisory Group (ECPAG) Association of Ambulance Chief Executives AACE’s National Directors of Operations Group National Association of Ambulance Medical Directors 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 22 may 2019 I commenced an investigation into the death of Sarah Ferneyhough a 30 year old young woman who died on 22 May 2019 at Halstead. The investigation concluded at the end of the inquest on 10 February 2020. Abels Road The conclusion of the inquest was expressed as a Narrative viz:- The deceased died at her home address in the early hours of 22 May 2019. She had taken an overdose of venlafaxine, amisulpride and hydroxyzine as well as cocaine, cannabis and alcohol. At 23.53am on 21 May 2019 she called the ambulance service but on attendance of fire and ambulance crews at 3.04am on 22 May she could not be resuscitated. There was a delay in the attendance and failings in the procedures in place for the categorisation of calls. It is not certain whether, if paramedics had arrived sooner, she would have survived. The evidence does not indicate on the balance of probabilities that the deceased intended to take her own life. CIRCUMSTANCES OF THE DEATH See above The medical cause of death was 1a) alcohol and multiple drug toxicity CORONER’S CONCERNS 4 5 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. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as a category 3 A review of this practice is required. 1 2. A review is required as to whether it is appropriate for all reported medical 3. conditions to be categorised no higher than category 3 In the situation leading up to Ms Ferneyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. 1. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 16th December 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 – East of England Ambulance Trust – Hempsons solicitors Solicitors for the family 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 Mrs Caroline Beasley-Murray senior coroner Essex 2
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.
NHS East of England Ambulance Service NHS Trust Ms Caroline Beasley-Murray East of England Ambulance Service NHS Trust Senior Coroner for Essex Whiting Way Melbourn Essex.CoronersService@essex.gov.uk Cambridgeshire SG8 6NA 14" December 2020 Dear Ms Beasley-Murray Thank you for your communication regarding the Regulation 28 (Report to Prevent Future Deaths) in respect of the death of Sarah Ferneyhough. | would like to offer my condolences to Sarah’s family and those affected by this tragic event. | can confirm we have distributed the report to the four organisations named in the report as per your request. AACE have confirmed they have reviewed the Trust’s response and we are awaiting feedback from the other groups. | have responded to the points raised in the Regulation 28 report separately below: 1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as a Category 3. A review of this practice is required. The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call. There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust's governance and approval process. This will be completed and released in December 2020. Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include: e Chest Pain e Breathing Difficulty e - Loss of consciousness e Severe haemorrhage (bleeding) e Stroke e¢ Pregnancy/Labour ¢ Overdose Chief Executive: = Chair: <_—— #WeAreEEASTAC * Calls with a mental health element such as suicidal intent, thoughts or threats, serious self- harm or mental health crisis 2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than Category 3 The Trust is awaiting a response on national coding but in the meantime has introduced the measures as described above to enable higher risk calls to be escalated and coded as a Category 2 where appropriate. 3. In the situation leading up to Ms Ferneyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given. The ESOP on Abandoned Calls, in development, will now also include a series of checks that must be undertaken by the control room Duty Manager. This includes a requirement to listen to the call recording to ensure details given are accurate and the response is appropriate. This will also facilitate clinical escalation and review where required. | hope this letter demonstrates the steps the Trust is taking in relation to our management of abandoned calls and calls where there are concerns about a patient's mental health. Please do not hesitate to contact me should you require a further update. Acting Chief Executive Officer Chair: www.eastamb.nhs.uk #WeAreEEAST
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