Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0036, written 11 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2021 |
|---|---|
| Reference | 2021-0036 |
| Deceased | Jack Goodwin |
| Coroner | Alison Mutch |
| Coroner area | Greater 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: NHS England 1 CORONER I am Alison Mutch , Senior Coroner, for the Coroner Area of Greater Manchester South 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 January 2020 I commenced an investigation into the death of Jack Goodwin. The investigation concluded on the 21stJanuary 2021 and the conclusion was one of narrative: Died from the complications of a hypoxic brain injury that had occurred following a cardiac arrest when there was a significant period before circulation was restored. The medical cause of death was 1a) Chest Infection on a background of hypoxic brain injury 1b) Cardiac arrest 1c) Ischaemic and hypertensive heart disease II) Urinary Tract Infection 4 CIRCUMSTANCES OF THE DEATH On 15th December 2017 Jack Goodwin was at an address in Timperley when he experienced chest pains. Contact was made with the ambulance service at 09:49. The call was categorized as a category 2 call, requiring an average response within 18 minutes and 9 out of 10 within 40 minutes. The call lasted 5 minutes and 19 seconds. Jack Goodwin deteriorated and a decision was taken to drive him to a hospital as it was believed the ambulance was likely to be delayed due to the level of busyness indicated by the call operator. At 10:01 the ambulance was cancelled and he was en-route to Altrincham Hospital. The hospital chosen did not have an A & E department and is not an acute hospital. At 10:07 a further call was made to NWAS indicating Jack Goodwin was still in the car but was now unconscious. 1 At 10:10 the address (outside Altrincham Hospital) was verified and emergency services were dispatched at 10:12. They arrived at 10:20. That call was categorised at category 1. On arrival of NWAS a defibrillator was being used on Jack Goodwin. He was in ventricular fibrillation. At 10:44 there was a return of spontaneous circulation and he was transferred to Wythenshawe Hospital. Cardiac investigations found no clear cause of the cardiac arrest. He had sustained a significant hypoxic brain injury as a consequence of the prolonged downtime. He had significant cognitive impairment and as a consequence was at risk of aspiration pneumonia and chest infections. Catheterisation that was required as a consequence of his reduced cognitive function made him susceptible to urinary tract infections. He required significant assistance with daily living. In January 2020 he had deteriorated further and had on the balance of probabilities developed a chest infection. On 15th January 2020 he died at his home address Cheadle, from complications arising from the cardiac arrest and prolonged downtime he suffered on 15th December 2017. , 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. The inquest heard that at the time of the calls to NWAS on 15th December 2017 they were very busy. The script used by the call handler allowed them to indicate that they were busy. However it did not allow for any suggestion or discussion about whether he would be better to make his own way there or allow for the provision by the call handler of a realistic timescale for the ambulance arriving. As a consequence it was difficult for the call maker to make an assessment of the best course of action to ensure that Mr Goodwin received medical attention at the earliest opportunity. 2. When a decision was made to take Mr Goodwin direct to the hospital and NWAS were told. There was no provision within the script to emphasise that the hospital would need to be an acute hospital with an A and E department. 3. There was an indication that given that if Mr Goodwin deteriorated then a further call should be made to NWAS. The evidence before the inquest was that this was not emphasised in such a way within the script to ensure that the call maker understood that this was 2 key to ensure there could be a further assessment of urgency. 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 8th April 2021. 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 may find it useful or of interest. , wife of Mr Goodwin, who 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 Alison Mutch Senior Coroner, for the Coroner Area of Greater Manchester South 11/02/2021 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.
HMC Ms Alison Mutch Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 23 September 2021 Re: Regulation 28 Report to Prevent Future Deaths – Jack Goodwin (15 January 2020) Thank you for your Regulation 28 Report to prevent future deaths (hereafter “report”) dated 11 February 2021 concerning the death of Jack Goodwin on 15 January 2020. Firstly, I would like to express my deep condolences to Jack’s family. I am sorry that my response has been delayed. Your report concludes Jack Goodwin’s death was a result of: 1a) Chest infection on a background of hypoxic brain injury 1b) Cardiac arrest 1c) Ischaemic and hypertensive heart disease II) Urinary Tract Infection Following the inquest, you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) about the call script not allowing for discussion about the call maker making their own way to the emergency department or providing a realistic timescale for the ambulance arriving. All ambulance services are responsible for having in place scripts and procedures for dealing with delays in responding when under operational pressure. It is not possible in practice to offer an accurate arrival time for any given patient, but ambulance services will know an approximate current waiting time for that category of patient. NHS E/I support a position that callers should be provided with sufficient information to make informed decisions if an ambulance has not been despatched to the patient. The Ambulance Transformation Forum, chaired by NHS E/I and including representatives from all ambulance services in England, discussed this in April 2021. Following piloting of the provision of an estimated time of arrival it was concluded that providing an accurate estimated time of arrival for an ambulance that had been dispatched to a patient is not practicable, largely due to the common and necessary NHS England and NHS Improvement practice of diverting lower priority ambulance responses to higher priority incidents. This could lead to patients receiving multiple cancellations and renewed estimated times of arrival. There was strong support for providing more accurate likely waiting times particularly for lower acuity patients. Ambulance services have committed to amending their case exit scripts, where necessary, to provide an estimated waiting time for these lower acuity calls. During the Covid-19 pandemic ambulance services have also enhanced their case exit scripts where significant delays may have occurred to advise callers of the option, due to the long estimated waiting time, that they could make their own way to an emergency department or urgent treatment centre. Furthermore, you raised the following concerns and I include my response to each in turn: 1) the call script having no provision to emphasise that the patient needed to be taken to an acute hospital with an emergency department 999 calls to the ambulance service can be answered anywhere in the country so we cannot rely on local knowledge; call handlers do not have immediate access to which is the nearest emergency department in those situations where a caller advises that the patient would make their own way to hospital. In appropriate circumstances, NHS E/I consider that advising the caller that they should make their way to the nearest emergency department, noting that not all hospitals have emergency departments, would be a useful addition to the script callers receive. This will be explored through the Ambulance Transformation Forum. 2) the call script did not emphasise in such a way the importance of the call maker making a further call if Mr Goodwin’s condition further deteriorated so that there could be a further assessment of urgency Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If this was not provided in a clear and easy to interpret manner this is a matter for ambulance services to resolve locally as a training issue for call handlers. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director NHS England and NHS Improvement
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