Raphael Gill

Mr Jonathan Landau 
HM Assistant Coroner for Greater London South  
Croydon Coroner's Court  
2, Davis House 
Robert Street 
Croydon  
CR0 1QQ 

Legal Services 
Headquarters 
220 Waterloo Road 
London 
SE1 8SD 

22 June 2022 

Dear Sir 

Regulation 28; Prevention of Future Deaths Report (PFD) arising from the inquest into the death of Raphael 
Jeffery GILL 

Thank you for your Regulation 28 Report dated 27 April 2022, setting out your concerns to be addressed.    

I would like to begin by expressing my deepest condolences to the family of Mr Gill on their loss. 

The concerns set out in your PFD report were that Mr Gill was not transferred to the hospital under emergency 
conditions (blue lights and sirens) on 11 December 2019. You further highlight that the more senior clinician 
(the  paramedic)  drove  the  ambulance  to  the  hospital  while  their  Emergency  Medical  Technician  (EMT) 
colleague attended to Mr Gill in the rear of the ambulance. You advised that the jury found that the ambulance 
clinicians  were  unaware  that  the  combination  of  seizures  and  cocaine  represented  a  medical  emergency.  In 
addition, you have highlighted that you found that the fact Mr Gill was under arrest by police unduly influenced 
the assessment of urgency. 

I requested that an 'end to end' review of this case be undertaken. Following this, our Chief Paramedic, Chief 
Medical Officer, Director of Corporate Services, and Consultant Paramedic have completed this review and the 
findings were presented to the private session in Trust Board on 31 May 2022. This review has been used to 
inform our response. 

I will set out the LAS response to these as follows:  

Decision not to convey Mr Gill to hospital under emergency conditions 

On  arrival  of  the  ambulance,  Mr  Gill  presented  with  an  increased  heart  rate  of  127  beats  per  minute,  an 
increased  respiratory  rate  of  28  breaths  per  minute,  and  a  slightly  elevated  blood  pressure  at  157/82.  This 
would equate to a NEWS 2 (National Early Warning Score Second Edition) of five. This would put the patient in 
medium risk stratification using the NEWS score. The NEWS 2 score is a nationally validated tool for assessing 
clinical  acuity  and  has  been  evaluated  empirically  for  use  pre-hospital.  Mr  Gill's  physiological  observations 
improved en route to hospital providing some clinical reassurance.     

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 Mr Gill remained fully conscious while with the LAS. The police had reported that Mr Gill had four episodes of 
seizure-like activity with  his  arm and legs going stiff whilst  he was  in the police  car, each lasting around one 
minute before the arrival of the LAS, there is no evidence recorded of tongue biting or incontinence, both of 
which  are  often  seen  in  tonic-clonic  seizures.  It  appears  from  the  police  statements  that  Mr  Gill  recovered 
between  each  of  these  events.    The  ambulance  clinicians  describe  Mr  Gill  as  having  episodes  of  muscular 
rigidity  while  in  their  care,  but  he  remained  alert  and  talking.  Mr  Gill  denied  taking  cocaine  that  day  but 
reported having previously consumed cocaine the day before. Mr Gill had a history of seizure activity but was 
not routinely medicated for this.  

The history of recurrent seizure type activity is clinically concerning. The recovery between seizures indicates 
that this was not a continual or status seizure1. 

Mr  Gill  was  appropriately  assessed  and  promptly  conveyed  to  the  local  emergency  department.  We  have 
considered  carefully  if  a  pre-alert  call  (blue  lights  and  sirens)  was required. On  balance,  there  is  no  absolute 
indication  that  a  pre-alert  call  was  required.  Mr  Gill  was  fully  conscious  and  able  to  walk  himself  into  the 
hospital.  The  time  from  the  arrival  of  the  conveying  ambulance  on  the  scene  to  leaving  the  scene  for  the 
hospital was 18 minutes; this is rapid and, on balance, could not have been quicker. Therefore, the LAS believes 
that this does not reflect a lack of urgency, that the time spent on the scene was not excessive and it does not 
follow that the fact Mr Gill was under arrest influenced the timeliness or appropriateness of his assessment, 
management or of his care.   

The  decision  to  place  a  pre-alert  call  has  to  sit  with  the  clinicians  attending  to  the  patient.  To  provide  a 
definitive list of circumstances where a pre-alert call is mandated would produce  a document of such length 
and complexity that its day-to-day use would be close to impossible. It would have to cover many a multitude 
of  medical  and  traumatic  conditions  and  patient  presentations.  Where  a  patient  is  fully  conscious  and  has 
clinical observations within the medium NEWS2 risk stratification, we would hold that a pre-alert call would not 
be  mandated.  It  is  worth  noting  that  pre-alert  calls  have  to  be  balanced.  Their  overuse  can  adversely  affect 
clinical safety within an Emergency Department, as they will distract from the routine assessment of patients 
waiting  to  be  assessed  as  well  there  is  a  balance  of  risk  to  be  struck  around  driving  under  emergency 
conditions. The LAS continues to work with Emergency Departments across the Capital to ensure patients are 
handed over and assessed promptly upon their arrival. On Mr Gill's arrival, I note that a handover was provided 
to  clinical  staff  within  the  department,  which  included  a  copy  of  the  LAS  clinical  record  containing  Mr  Gill's 
clinical observation. 

Primacy of care       

The LAS  recognises  that  the  paramedic  drove  the  ambulance  to  the  hospital while  her  clinically more  junior, 
non-registered colleague remained in the back of the ambulance attending to Mr Gill. On balance, despite Mr 
Gill being fully conscious, there was a history of abnormal muscle rigidity and possible seizure activity. As such, 
we would be of the view that the paramedic should have attended to Mr Gill in the rear of the ambulance as 
they  would  have  been  immediately  available  in  the  case  of  deterioration.  As  you  will  be  aware  from  the 
documentation  provided  to  you  at  the  close  of  the  inquest,  the  LAS  has  a  number  of  guidance  notices  and 
policies around the primacy of care. In addition, there is helpful documentation from the professional regulator 
on  this  subject.  We  have  undertaken  to  review  the guidance  we  have  in  place  and  to  see  if  we  can make  it 
more accessible by providing examples as to when we would expect a paramedic to travel directly attending to 
the patient. 

1 Brophy, Gretchen M., et al. Guidelines for the evaluation and management of status epilepticus. Neurocritical care 17.1 (2012): 3-23 PMID: 22528274 
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 Patients under the influence of cocaine 

Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are 
aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may 
present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal 
Colleges  Ambulance  Liaison  Committee  (JRCALC)  Clinical  Guidelines  and  is  of  the  view  that  these  contain  a 
detailed  set  of  guidelines  for  the  management  of  patients  who  have  used  cocaine  and  seizure  activity  is 
specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow 
for consideration of further review of the guidance.  

In terms of the LAS, we will produce an internal clinical refresher for all frontline clinicians, which will be shared 
in  our  internal  'Clinical  Update'  publication  around the  risks  associated  with  cocaine  to  continue  highlighting 
the  'red  flag'  presentations  in  respect  of  patients who  have  used  cocaine.  This  is  planned  to  be  published  in 
early Autumn 2022.  

I hope our response assures that the LAS has robustly reviewed the care provided to Mr Gill and will continue 
to take actions where learning has been identified.       

Yours faithfully 

Chief Executive, London Ambulance Service NHS Trust   

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