Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0037, written 4 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2022 |
|---|---|
| Reference | 2022-0037 |
| Deceased | Sarah Gilbert-Jones |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Emergency services related deaths (2019 onwards) · Mental Health related deaths · Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Organisation named | Welsh Ambulance Services 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: at Welsh Ambulance NHS Trust 1 CORONER I am Graeme Hughes, H M Senior Coroner, for the coroner area of South Wales Central. 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) Reg ulations 2013. 3 INVESTIGATION and INQUEST On 3.11.20, I commenced an investigation into the death of Sarah Marie GILBERT- JONES. The investigation concluded at the end of an inquest on 3rd February 2022. The conclusion of the inquest was:- The deceased died due to the direct effects of a significant and deliberate overdose of her prescription medication. It is unlikely that she intended the c ons equenc es of t hat overdose to be her own death. It is likely that the timing of her death was contributed t o by her sub-optimal transfer to hospital, narrowing t he opport unit y f or ad minis tering ef f ective life-saving medication and treatment. The cause of death being: 1a: Toxicity 4 CIRCUMSTANCES OF THE DEATH These were recorded as :- Since 2019, Sarah Marie GILBERT-JONES, had experienced fluctuating and worsening mental health. This had manifested itself in episodes of self-harm, and from the summer of 2020 overdoses of her prescription medication. On the evening of 28.10.20 she has taken a significant overdose, concurrently with a large quantity of alcohol. A delay in the arrival of the emergency services compromised an opportunity for earlier life-saving treatment. She died in the early hours of 2910.20 at the Royal Glamorgan Hospital. The cause of her death due directly to the toxic effects of the overdose. The Inquest broadly focused upon:- a. The emergency response following notification of the overdose & request for ambulance assistance. In particular, the grading of calls to the Clinical Contact Centre & the actions initiated following the same b. Whether a delay(s) in ambulance service attendance (upon the deceased) & 1 conveyance to an Accident & Emergency Department, contributed to her death c. The contribution, if any, of sub-optimal Mental Health Services provision upon her death 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) When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it was accepted that he explicitly indicated to the Call Handler that the tablets. deceased had taken an overdose of, inter alia, Based upon that, & answers to other questions posed by the call handler, the call handler selected a protocol which did not appear to require this crucial piece of information to be either recorded within it, or to form part of the material which led to the categorisation of the call for the purposes of determing the appropriate response. In short, it led to a categorisation which could only loosely provide a response (based upon the level of demand that evening) estimate of around 3 hours. The concern here is that treatment for a massive overdose is time critical, & the processing of the call did not appear to accurately reflect the peril the deceased was then in, nor the importance of providing an acute emergency response. (2) There appeared to be an opportunity shortly following the initial categorisation of the response, by a clinical floor walker, to upgrade to a code/categorisation which would likely have led to a swifter response, but an under-appreciation, or otherwise, of the then time critical treatment window open to the deceased. I was inf ormed in evidence that the clinical floor walker would have had access to TOXBASE via the Clinical Support Desk at that time, & had that been accessed & inf ormation promptly secured regarding the treatment indicated, this would have alerted the clinician to the need for an acute emergency response. This was subsequently undertaken by the attending paramedic (albeit not via TOXBASE) some hours later, & who immediately after having accessed the overdose, appreciated that the deceased treatments for massive was a time sensitive patient & to convey to the emergency department with all haste. (3) Following the second call to Clinical Contact Centre at 23.48 on 28.10.20, there were somewhat bewilderingly complex, & inconsistent categorisations of the code for response which appeared to lead to response vehicles being despatched or stood down, whilst the patient remained in need of time sensitive treatment by way of transfer to an Accident & Emergency Unit. Whilst I was assured that this had been addressed by learning & guidance to call handlers, a review of categorisations, coding’s & actions in the setting of a patient demonstrating the symptoms as per the deceased on 28/29 October 2020 to achieve clarity/consistency is invited. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your 2 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 1st April 2022. Only, I, the Coroner, may extend the period. Your response must contain details of action taken or p roposed 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 deceased’s family and the Health Inspectorate Wales, Cwm Taf Health Board who may find it useful or of interest. 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 f orm. 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 4th February 2022 SIGNED: Graeme Hughes, H M Senior Coroner for South Wales Central 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.
Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office 31 March 2022 PRIVATE & CONFIDENTIAL Mr Graham Hughes HM Senior Coroner at South Wales Central Dear Mr Hughes Sarah Marie Gilbert-Jones I write in response to the Prevention of Future Deaths Report issued to this Trust on the 4 February 2022, following the inquest in relation to Sarah Marie Gilbert-Jones. I understand that, whilst giving evidence, my staff provided you with details of changes that the Trust has already made (since this incident), that would have affected how we respond to such a call received today. I will not repeat that information here, but rather build on those changes. The issue of Propranolol overdose has already been discussed at the International Academies Of Emergency Dispatch (IAED) Clinical Focus Group, initially raised by another ambulance service. This is not an issue being faced here in Wales alone. One consideration has been as to whether there is a specific question set, with associated code group and priorities, which will identify the case as a propranolol overdose. The Medical Priority Dispatch System (MPDS) already has a question set that relates to Fentanyl which was an issue in some countries. The issues of instigating different actions for different drug types are twofold. There is the fact that the individual drugs that can be involved in overdose cases are many and varied. Additionally, this moves away from the basis of the Trust’s Clinical Response Model, where the sickest patients are identified and attended first. This Model is based on the patient’s condition at the time and is not based on potential future changes to their conditions. Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.wales.nhs.uk Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol Regional Ambulance Headquarters and Clinical Contact Centre Tŷ Vantage Point Vantage Point House Tŷ Coch Way Cwmbran NP44 7HF Ffôn/Tel 01633 626262 During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident. That flag identifies the case as an overdose of such things as Propranolol, and is visible for the staff responsible for dispatching vehicles. This flag indicates to the Allocator that a vehicle should be sent as soon as possible and that allows the dispatch teams to consider allocating available resources out of time order (as resources are normally dispatched to the highest priority/oldest call first). I attach for your reference a plan that lists the actions the Trust is proposing to consider in order to address the issues highlighted within your Regulation 28 report. Any changes made will be included within the Trust’s Standard Operating Procedures (Clinical Contact Centre and Clinical Support Desk). Whilst writing I would like to extend my sincere condolences to Miss Gilbert-Jones family on their sad loss. I am pleased to hear that they have accepted the Trust’s offer to reconsider this matter under the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continuance improvement to support the prevention of future deaths. Yours sincerely Chief Executive Enc: Action Plan 2
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