Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0011, written 14 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jan 2021 |
|---|---|
| Reference | 2021-0011 |
| Deceased | Karl Bolam |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Emergency Services related deaths |
| Organisation named | South East Coast Ambulance Service NHS Foundation 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Karl James BOLAM
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
• NHS Pathways, nhspathwaysclinicaldirector@nhs.net
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Karl James BOLAM was opened on 29th
August 2018. It was resumed and evidence was heard on 7th June 2019
and 8th October 2020, when it was concluded.
I found the medical cause of death to be:
1a. Subdural Haemorrhage
1b. Head Injury
1c. Fall
I determined that Mr Bolam died from a head injury he sustained in a fall
at his home address in the early hours of 14th August 2018. He first
telephoned for an ambulance at 1.09am and placed two further calls to
chase attendance at 2.07am and 2.21am but the ambulance did not attend
until 3.42am and located Mr Bolam at 4.10am, by which time he was
unconscious with a Glasgow Coma Score of 3/15.
4 CIRCUMSTANCES OF THE DEATH
Mr Bolam called 999 at 1.09am on the morning of 14th August 2018
stating; “I was a little bit drunk and I slipped and I split my head open.”
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He was categorised as a Category 2 disposition (Emergency, potentially
serious incident) by call handlers at South East Coast Ambulance Service
(SECAmb), requiring an 18 minute maximum response time.
Unfortunately due to demands on the service, including a major incident
the previous day, paramedics did not attend his home until 3.42am, and
located Mr Bolam unconscious in the back garden of his home address at
4.10am. Mr Bolam had called 999 again at 2.07am and 2.21am stating that
he felt worse, and welfare calls were made by a Clinical Supervisor from
SECAmb at 1.14am and 1.37am.
Mr Bolam was taken by air ambulance to Kings College Hospital where
he was found to have very poor prognosis and he died on 17th August
2018 without having regained consciousness.
5 CORONER’S CONCERNS
Mr Bolam resided with his friend and Landlord at his home address, who
was unaware of Mr Bolam’s accident and resulting head injury until
paramedics attended at 3.42am on the morning of 14th August 2018. He
was therefore unable to offer any assistance to Mr Bolam although
willing to do so had he been aware.
I heard evidence that SECAmb were in purple surge management plan at
the time, meaning the service was unable to meet operational demand.
Calls between Mr Bolam and the call handlers and Clinical Supervisor
from SECAmb were played at the Inquest, and Mr Bolam stated that he
was on his own. I heard that he was not asked whether there was anyone
he could contact to be with him, particularly noting the long delay in
paramedics being able to attend.
I was advised by SECAmb that the questions asked by their operators are
set by NHS Pathways, but that they intended to raise this issue for NHS
Pathways to consider amending their scripts to positively advise lone
callers to call someone to be with them.
SECAmb updated the Court with the response from NHS Pathways on
8th December 2020 as follows:-
NHS Pathways has made changes in relation to the ambulance closing
instructions provided to first party callers that are alone. An additional
instruction was inserted for Release 19.2 regarding calling someone else
as follows – “If you do need to contact somebody do so now, then try
and keep the line free as we may need to call you back”.
With regards to this case, no additional changes have been identified
from the information provided. We are unclear as to what the ask is, nor
who is responsible for taking this further. NHS Pathways has provided
an email correspondence address for the coroner to raise any questions or
queries.
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In the meantime, this issue will be closed due to the changes made in
Release 19.2.
I do not believe this issue has been adequately addressed by the
amendment in Release 19.2, and that the script provided by NHS
Pathways for use with emergency callers should be amended positively
to persuade callers to call someone to be with them, and particularly
when a delay in paramedic attendance is anticipated. SECAmb have also
expressed disappointment with this response.
The MATTERS OF CONCERN are:
1. The script currently used by NHS Pathways in respect of
emergency callers does not positively persuade callers to call
someone to be with them, particularly in circumstances where
paramedic attendance is delayed due to demands on the service.
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3.
, Head of Legal Services, South East Coast
Ambulance Service NHS Foundation Trust
4. The Chief Coroner
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In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 14th day of January 2021
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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.
HM Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
Surrey
GU22 7AP
Email correspondence to:
Our Reference:
Dear Ms. Anna Loxton
Inquest into the death of Karl James Bolam
1 Trevelyan Square
Boar Lane Leeds
LS1 6AE
25th February 2021
I am writing in response to the Regulation 28 report received from HM Assistant Coroner, dated
14th January 2021. This follows the death of Karl James Bolam who sadly died on the 17th August
2018. This was followed by an investigation and inquest which concluded on 8th October 2020.
We would like to express our sincerest condolences to the family of Karl James Bolam.
Unfortunately, NHS Digital was not informed that this inquest was occurring, and it is disappointing
that we did not have the opportunity to provide information and address your concerns directly.
NHS Pathways is the clinical decision support software used by all 111 service providers, and
some 999 ambulance service providers including South East Coast Ambulance Service NHS
Foundation Trust (SECAmb). For information, I have included a short summary of the functions
that NHS Pathways performs and the governance that underpins it (containing background
information on NHS Pathways) in Annex A. I also enclose the HM Coroner’s Information Pack
(containing background information on NHS Pathways), please see Annex B.
HM Coroner has raised the following matters of concern with regards to NHS Pathways:
1. The script currently used by NHS Pathways in respect of emergency callers does not
positively persuade callers to call someone to be with them, particularly in circumstances
where paramedic attendance is delayed due to demands on the service. Consideration
should be given to whether any steps can be taken to address the above concerns.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
NHS DIGITAL’S RESPONSE
For all calls that go through NHS Pathways, care advice and closing instructions are provided at
the end of each call by the health advisor or clinician. This advice instructs the patient how to
manage themselves either whilst waiting for an ambulance to arrive or another health care
professional to contact them. All callers are given specific worsening instructions to call back if
they have any new symptoms, or if the condition gets worse, changes or they have any other
concerns.
In addition to closing care advice and worsening instructions, disposition advice is provided to
inform the caller of the next steps, for example that an emergency ambulance is being arranged.
For NHS Pathways release 17 which was deployed from 5th May 2019, health advisors were
provided with an optional script to advise callers that an ambulance aims to be with you, within
eight or eighteen minutes or within one or two hours depending on the disposition reached. This
was introduced at the request of ambulance services to assist in managing patients' expectations
regarding the ambulance arrival.
Exact times of the arrival of an ambulance response cannot be given by NHS Pathways as this
information can only be provided by the 999 provider and is dependent on operational demands
at the time of the call.
NHS Pathways Script for a Category 2 ambulance response:
In both 999 and 111 (when using NHS Pathways) when an ambulance disposition is reached,
callers are advised to keep their contact number free in case the ambulance service needs to call
the patient back (for example to confirm the address or any special requirements like entry
information). This is especially important in calls generated from 111 as these are automatically
sent through to the ambulance service and the service that has received the case may need to call
back. This script forms part of the closing instructions and is agreed nationally with all ambulance
services using NHS Pathways.
This wording was reviewed in 2016 by NHS Pathways and the 6 ambulance service trusts using
NHS Pathways at the time. The agreement was for this instruction to remain.
Mr Bolam’s call was received on the 14th August 2018 and reached a Category 2 ambulance
response (aim to attend within 18 minutes). SECAmb has advised NHS Pathways they were using
release 16.0.1 at this time. Accordingly the instruction "Once this call is finished don't ring anyone
else in case we need to call you back" would have been given before the worsening advice.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
The wording was further reviewed in 2019 (details below) and in Release 19, deployed January
2020, amended to: "If you do need to contact somebody do so now then try and keep the line free
as we may need to call you back".
This change was applied to all closing instructions across the system, as per the example below:
Previous Version:
Changes applied from release 19:
All providers can, and are encouraged, to submit feedback, information, and requests to NHS
Pathways via the clinical or training issue log, or via a monitored mailbox. The 2019 review was
based on a request for change made to NHS Pathways by SECAmb on the 25th February 2019
suggesting inclusion of an instruction for patients who were alone to call someone. The request
for change was discussed at the 999 User Group. This group is formed by representatives from all
999 providers using NHS Pathways to enable discussion of requests for change, areas of good
practice and other relevant topics. NHS Pathways are invited and members of the clinical, training
and implementation team attend.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
The proposed changes were presented at the 999 User Group on 17th July 2019. South East
Coast, South Central, North East and West Midlands Ambulance Services were represented by
clinical and training leads. There was not a majority consensus regarding instructing a 1st party
caller to phone someone due to concerns listed below.
• 1st party callers ringing someone else may block the line and prevent the ambulance service
contacting the patient.
• A mandated instruction may invite dialogue regarding having no one to phone, no credit,
who to phone, which can increase call length.
• Family or friends could arrive after the ambulance which could lead to further calls into 999.
• Operational standard operating procedures (SOP’s) manage calls where there is a delay in
dispatch of an ambulance, including no contact welfare calls, therefore it is not for NHS
Pathways to mandate.
The group discussed the above risks, and possible options of: i) giving an instruction; ii) giving
advice; and iii) not changing the content. The group agreed that encouraging 1st party callers
waiting for an ambulance to ring family or friends if they wished to, and to do so straight away, was
safe and should be included. The wording above was agreed by the group and added to Release
19. NHS Pathways responded to SECAmb’s request for change, noting the agreed outcome from
the 999 User Group and did not receive any further communication from SECAmb.
In circumstances where paramedic attendance is delayed due to demands on the service.
Whilst using NHS Pathways, the health advisor may not be aware of delays within the 999 service.
This information is held on the 999 providers host system and does not influence the NHS
Pathways triage. Once an ambulance disposition is reached, the disposition script can be
amended by a provider or local SOP to require health advisors to give further information
depending on the circumstances. Demand management is maintained and managed within each
111 and 999 providers; therefore NHS Pathways is unable to mandate a script to persuade callers
to call someone to be with them if the ambulance is delayed.
Disposition Script:
NHS Pathways is currently reviewing if there is a need for the question “is the patient alone” to be
embedded within the NHS Pathways triage as an ‘information only’ tick box. This question is asked
by some providers during the collection of demographic information, primarily to assist with
safeguarding concerns, and to inform any onward provider of care post disposition that the patient
is alone. It is not proposed that it would alter dispositions reached within NHS Pathways. The
proposal is being discussed with users and providers to collate feedback.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
If HM Coroner requires any further clarification in relation to any points, please do not hesitate
to contact us and we can assist further.
Yours sincerely
Professor
Chief Medical Officer
NHS Digital
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
Annex A
Function of NHS Pathways
NHS Pathways is a programme providing the Clinical Decision Support System (CDSS) used
in NHS 111 and half of English ambulance services. This triage system supports the remote
assessment of over 18 million calls per annum.
These calls are managed by non-clinical specially trained health advisors who refer the
patient into suitable services based on the patient’s health needs at the time of the call. Health
advisors are supported by clinicians who are able to provide advice and guidance or
who can take over the call if the situation requires it. The system is built around a clinical
hierarchy, meaning that life-threatening problems assessed at the start of the call trigger
ambulance responses, progressing through to less urgent conditions which require a less urgent
response (or disposition) in other settings.
Governance of NHS Pathways
The safety of the clinical triage process endpoints resulting from a 111 or 999 assessment using
NHS Pathways, is overseen by the National Clinical Governance Group, hosted by the Royal
College of General Practitioners. This group is made up of representatives from the relevant
Medical Royal Colleges. Senior clinicians from the Colleges provide independent oversight and
scrutiny of the NHS Pathways clinical content.
Alongside
this independent oversight, NHS Pathways ensures its clinical content and
assessment protocols are consistent with the latest advice from respected bodies that provide
evidence and guidance for medical practice in the UK. In particular, we are consistent with the
latest guidelines from
• NICE (National Institute for Health and Clinical Excellence)
• The UK Resuscitation Council
• The UK Sepsis Trust
Annex B
Coroner’s Information Pack
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
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