Lisa Codling

RECEIVED
12 APR 2021

South East Coast
Ambulance Service
NHS Foundation Trust

Trust Headquarters
Nexus House
Gatwick Road
Crawley

Mrs V. Hamilton-Deeley West Sussex

HM Senior Coroner for Brighton and Hove RH10 9BG

By email only
Www.secamb.nns.u

12 April 2021

Dear Madam

The late Ms Lisa Codling

| write by way of SECAmb’s response to the Regulation 28 Prevention of Future Deaths report
issued in this matter on 19 February 2021.

| was very sorry to hear of Ms Codling’s passing and | would like to pass my personal
condolences to her family and friends. Please be assured of our commitment to undertake
critical self-reflection that seeks to improve the service we offer and to support patients like
Ms Codling.

Your report which you address to me was also addressed to my Medical Director and her
Deputy and Assistant. | write this response on behalf of all parties, after collaborating with
them in the investigation of the matters raised in your report.

History of the incident

| thought it may be helpful for others reading this response, who did not have the benefit of
attending the inquest, if | set out a brief history of the events of 5 September 2020. Ihave
summarised and limited details around Ms Codling’s personal circumstances in the interest of
sensitivity:

19:30 SECAmb received a call from Ms Codling’s partner. He was outside her house and was
concerned that he had seen her take paracetamol tablets, with the possibility that she had
taken more. He thought that she was suffering a psychotic episode, following an upsetting
conversation with him about family matters. The call reached a Category 3 disposition; the call
taker called back Ms Codling first-hand, who denied taking an overdose or having any mental

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health issues. Notwithstanding this, the call taker decided to Pass the matter to an
appropriate registered clinician for further assessment.

20:08 A specialist Mental Health Nurse within SECAmb’s Emergency Operations Centre
called Ms Codling. Again, during this call Ms Codling denied having taken an overdose, having
any suicidal ideation or having a mental health crisis, despite much careful probing by the
clinician. Although Ms Codling denied a need for medical assistance, the clinician persuaded
and successfully sought consent for her to agree to an ambulance attending to check her over.

20:20 The call with the clinician ended and the call was placed into the queue for a Category
3 ambulance, with a target to respond within two hours of the initial call.

21:53 An ambulance was assigned to Ms Codling but was redirected shortly thereafter to
attend a higher priority call.

22:20 A welfare call was made by SECAmb to Ms Codling’s partner. He informed the caller
that he had received a text from Ms Codling which read “It’s too late”.

22:33 Another ambulance was assigned to attend Ms Codling.

22:40 The ambulance arrived at Ms Codling’s address and she was found in cardiac arrest.
Attempts to resuscitate her were unsuccessful.

Investigation of the incident

An investigation was carried out into this incident by our Head of Integrated Governance for

111 and 999, MM and one of our Operations Managers with responsibility for

clinicians in our Emergency Operations Centre, Their report was submitted

to the Court prior to the inquest and a copy is appended to this letter. The key findings were:
** The Trust had implemented (from 1 May 2020) a process that exceeded NHS
Pathways’ current requirements by referring intentional/unintentiona! overdose calls
to a clinician; that new process was correctly followed.

“ The Mental Health Clinician successfully negotiated with Ms Codling, who denied
taking an overdose, to have an ambulance attend; without such professional
negotiation it is apparent that Ms Codling, who evidently presented as possessing
Mental Capacity, would have chosen to have no response.

“At all stages SECAmb preferred the information from Ms Codling’s partner and acted
accordingly and in her best interest.

“* Ms Codling’s partner stated that he had seen her take [paracetamol tablets. This
was the baseline information which would not have been a toxic overdose based on
the average size of an adult female, and this was confirmed by post mortem findings.

** In all senses SECAmb did treat this as an important issue and recognise that the patient
needed to be seen and ultimately conveyed to hospital by an ambulance crew (unless
she was deemed to have capacity and refused).

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** When the Mr Codling’s post mortem and toxicology reports were received, a further
detailed review of the case was undertaken

The email referred to in the Regulation 28 report

The Regulation 28 report refers to an email sent by | iQ yourself on 12 October
2020. [MM is SECAmb’s Head of Legal Services and provides pre-inquest information
to the court in order to assist the Coroner’s enquiries. Upon enquiry as to why the incident
had not been declared a Serious Incident (S!), EEE provided the reasons that the
Serious Incident group did not declare the incident as an SI. The matter quoted in the
Prevention of Future Deaths report was one of ten reasons provided within this email:

° The Trust’s new Overdose Operational bulletin was correctly followed

° In accordance with that bulletin, the case was referred by the call taker to a clinician

° The patient was called back by a SECAmb specialist Mental Health clinician who was able
to have a conversation with the patient and conducted a robust first party triage

° The patient denied having taken an overdose despite probing

° Although the patient stated that she was fine and had not taken an overdose, the Men-

tal Health clinician still decided to send an ambulance to the patient and upgraded the case
from a category 5 non-ambulance disposition to a category 3 disposition, an ambulance attend-
ance with a target response time of two hours

. The call has been audited and found to have been compliant, scoring 99/100

° The call back to patient by the Mental Health Clinician was made half an hour later than
target but this did not have any causal effect; the patient was alert and responsive when called

° Although we did not meet our target time to attend the patient after the call was upgraded

to a category 3 ambulance attendance, we believed that we were attending not an overdose case
but rather a mental health cause for concern case, which may have affected dispatching and clini-
cal queue monitoring decisions

. Clinicians advised that paracetamol will not kill a patient within a three-hour timeframe
although a paracetamol overdose should still be considered a time sensitive emergency
. Correct processes had been followed.

The report Ee rc this email in that they provided a section
in the report devoted to why the matter had not been declared an SI.

Incidence of acute paracetamol toxicity

Rapid death as a result of paracetamol ingestion is a very rare event. The members of our
Serious Incident group, which includes a multi-professional team of consultant and other
senior clinicians from medicine, paramedicine and nursing, had not witnessed or encountered
this presentation. Our Medical Director and Assistant Medical Director, who are both
experienced Consultants in Emergency Medicine, had not encountered any such cases, nor
had their Consultant in Emergency Medicine colleagues. It is for this reason that it was stated
in the Serious Incident group that patients do not die from paracetamol overdose within a
three hour timeframe. Clinicians’ experience of fatality following paracetamol overdose is a

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slow progression of toxicity over a period of days to weeks, generally as a result of acute liver
failure.

Clinical literature supports the rarity of the presentation of acute lactic acidosis arising from
mitochondrial inhibition following paracetamol overdose. The attached article from the British
Journal of Clinical Pharmacology (BJCP, Shah et al., 2011) refers to 24 reported cases within
the literature, reported between 1970 and 2010, of acute lactic acidosis following ingestion of
very large quantities of paracetamol. The research found a median of five hours from
ingestion to a reduced consciousness level and in 5 of the 24 cases the patient died.

This is triangulated with statistics from TOXBASE.org, the national toxic substance database,
showing that paracetamol had by far the greatest number of enquiries to their website, app
and telephone advice service in 2019-20, with over 165,000 enquiries (compared with
Ibuprofen in second place with just over 50,000 enquiries). The data reveals that whilst
paracetamol overdose incidence is high, acute acidosis as a result is extremely uncommon.

| note that in preparing for the inquest, the Trust’s clinical team considered both clinical
literature and the contemporary guidance on the management of paracetamol overdose.
Toxbase (2017) provides the guidance for healthcare in the UK on overdose. The relevant
guidance sheet for “Paracetamol overdose ingested over a period of one hour or less -
presenting less than 8 hours after acute ingestion” was reviewed (TOXBASE.org, 2020). This
guidance describes coma and severe metabolic acidosis as “extremely rare” and the
recommended care pathway for paracetamol ingestion is “Wait until 4 hours from the last
ingestion. Then take a venous blood sample for urgent measurement of the plasma
paracetamol concentration from all patients. Plasma concentrations measured less than 4
hours after ingestion cannot be interpreted.”. This information sheet was, | understand,
presented to the court for information.

Whilst provided in good faith, | recognise that the statement within the email of 12 October
2020 was not helpful to the court, and | apologise to Ms Codling’s family and friends for this.

Action that SECAmb has taken/proposes to take

We have:

1. Raised a formal issue with NHS Pathways (reference im to it to consider the matters
raised at inquest

2. Brought this case to the attention of the National Ambulance Service Medical Directors

3. Discussed the case with the NHS England / NHS Improvement national clinical lead who is
writing a new framework on triage and clinical oversight in EOC of overdose cases

4. Discussed with the Vice President of the Royal College of Emergency Medicine whether
they would flag this issue as a ‘Safety Alert’. The response was that in light of the rarity of
this presentation and possible confounding factors, he does not believe that a Safety Alert
would be appropriate.

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We further propose to:

5. Meet the NHS England national ambulance team

6. Meet NHS Pathways to share learning and progress the concerns we have already raised
on the Pathways issue log. Revised guidance on overdoses is at the pre-publication stage
(see attached email from ). This will endorse clinical review of overdoses,
with the intention of upgrading the call if appropriate. There will remain a degree of
discretion on the part of clinicians.

After careful consideration, we do not believe that it is feasible to upgrade all overdoses,
including paracetamol overdose, to a C2 disposition, as this would have a deleterious effect on
responses to those patients who are confirmed as requiring this level of response through
presenting with a potentially life-threatening complaints.

We have also considered whether any further internal training is indicated. Taking into
account the rarity of this presentation, the very limited volume of clinical information
available and the competing demands on limited training time, we have concluded that
further escalation is not indicated but rather that reliance on the Joint Royal Colleges
Ambulance Liaison Committee guidelines and Toxbase should continue.

Finally, | would like to reiterate my reassurance that we have taken this case very seriously,
we prepared a detailed report pre-inquest and we have sought to learn what we can both
before and after the inquest. We have already implemented best practice and continue to
take intentional/unintentional overdoses, self-harm and suicide extremely seriously.

Yours sincerely

Chief Executive Officer
South East Coast Ambulance Service NHS Foundation Trust

Encs: Report for inquest b
Email from

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