Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0281, written 14 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2020 |
|---|---|
| Reference | 2020-0281 |
| Deceased | Elsie Taylor |
| Coroner | Joanne Lees |
| Coroner area | Black Country |
| Category | Emergency Services 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. West Midlands Ambulance Service 1 CORONER I am Joanne Lees, Area Coroner for the coroner area of the Black Country Jurisdiction 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 30/9/20 I commenced an investigation into the death of Elsie Yvonne Taylor dob 14/2/52. The investigation concluded at the end of the inquest on 7/12/20. The conclusion of the inquest was a short form conclusion of accident. The medical cause for the death was established at post mortem as; 1a) Pneumothorax 1b) Rib Fractures 1c) Fall 2) COPD and IHD 4 CIRCUMSTANCES OF THE DEATH (1). The deceased was a 68-year-old lady who had a past medical history of chronic obstructive pulmonary disease, atrial fibrillation on anti-coagulation and ischaemic heart disease with stents. (2) On 15/9/20 she suffered a fall at her home address whereby she fell into a rose bush landing on her left-hand side. The fall was witnessed by a neighbour who helped her up. An ambulance was called approximately 1.5 hours later. (3) Paramedics attended and recorded left sided pain and bruising. There was no loss of consciousness and she was advised to take painkillers, was referred to her GP (with a discharge notice left) and verbally informed to contact emergency services if the pain or her breathing should worsen. (4) A further ambulance was called some 4 hours later where the deceased reported worsening pain and some difficulties breathing. A facial swelling was also noted with suspected allergic reaction. (5) She was taken to hospital where she had a chest drain inserted and was presenting as peri arrest. A cardiac cause was ruled out but sadly she deteriorated and passed away later the same day. (6) A post mortem revealed a pneumothorax and rib fractures consistent with a fall. 1 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 could 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 attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest; (2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer; (3) There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased; (4) There was no note left by the attending paramedic crew detailing the outcome of the consultation; (5) the discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission; (6) The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR). 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 8/2/21. 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 , daughter of the deceased and the CQC. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 2 You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 14/12/20 Joanne Lees Area Coroner 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.
Your Ref: N/A Our Ref: Ms J Lees Area Coroner for Black Country Jack Judge House Halesowen Street Oldbury B69 2AJ 8th January 2021 Dear Ms Lees Re: Regulation 28 Report to Prevent Future Deaths – Elsie Taylor (Deceased) Thank you for your email dated 11 December 2020 attaching your Regulation 28 Report. In your Regulation 28 Report. Please see our response to your concerns, which has been formulated following a clinical review with the paramedic who attended the Inquest. Concern 1 The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest; Response During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts expected standard of completing and checking documentation. We would like to apologise for the delay you experienced in receiving the statement. The local management team for the Black Country have been reminded of the importance of providing statements for your office in a timely manner. Concern 2 The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer; Response The paramedic acknowledged that the patient was on anti-coagulation medication, he informed the clinical review meeting that he advised the patient that she should go to hospital but the patient refused due to concerns about COVID -19. This discussion was not documented on the EPR. A safety net was put in place and the patient was asked to contact her GP or call 111/999 in the case of an emergency, this was documented on the EPR and discharge sheet. The patient was not asked to sign the EPR, this should have taken place for a non conveyance. As part of the further training attendend by the crew the importance of asking the patient to sign the non conveyance section of the EPR was covered. Concern 3 There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased; Response A discharge sheet was left with the patient, which detailed that the patient was to contact the GP or in the case of an emergency to call 999/111. The paramedic has confirmed that there was no family present but there was neighbour in attendance throughout the whole consultation. The neighbour was shown the bruise on the patient ribs and she informed the crew that she would stay with the patient for some time to keep an eye on her. Concern 4 There was no note left by the attending paramedic crew detailing the outcome of the consultation; Response Please refer response under concern 3 Concern 5 The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission; Response The box ticked on the discharge form states that the patient had been advised to contact or attend her GP practice. If a referral had been made on behalf of the patient one of the boxes at the top of the form would have been ticked. Concern 6 The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR). Response There was a neighbour in attendance throughout the consultation including at the point of discharge and it was the crews belief that she would stay with the patent. The patient stated that her daughter was at work and that she did not want her to be disturbed. Please be assured that both crew members have attended our training school and have completed a number of refresher training sessions to ensure they are fully trained in the areas discussed in their clinical case reviews. Can I please take this opportunity to pass on my sincere condolences to the family of Ms Taylor 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 Chief Executive Officer
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