Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0171, written 7 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jun 2022 |
|---|---|
| Reference | 2022-0171 |
| Deceased | Daniel Ludlam |
| Coroner | Katrina Hepburn |
| Coroner area | Kent (Central & South East) |
| Category | Emergency services related deaths (2019 onwards) |
| 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 THIS REPORT IS BEING SENT TO: 1. NHS Digital 2. Department for Health and Social Care 1 CORONER I am Katrina Hepburn, Area Coroner, for the coroner area of Central & South East Kent 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 6th January 2020 I commenced an investigation into the death of Daniel Robert Ludlam, 49. The investigation concluded at the end of the inquest on 26th May 2022. The conclusion of the inquest was death due to natural causes, contributed to by neglect. 1 4 CIRCUMSTANCES OF THE DEATH Daniel Ludlam had a history of moderate learning disability and had a package of care in place. Daniel had a hiatus hernia and despite hospital attendances earlier in the year presenting with gastrointestinal symptoms, this had not been investigated thoroughly. As a result, the severity of his underlying gastric condition was not known. On the 30th December 2019, Daniel complained of gastrointestinal symptoms of abdominal pain, haematemesis and melena. There was an initial delay in an ambulance being requested by his carers. During the initial call to the emergency services, Daniel had been too unwell to speak with the call handler on the telephone. He was in bed and the land line telephone was in another room. It was clearly stated to the call handler by the carer that due to Daniel’s learning disability, he may answer the questions with the response that he thought the questioner would want to hear, and that he may not answer the question accurately for that reason. Further, that he may not understand the question being asked. The carers assisted the call handler with relaying responses to the triage questions. The triage category allocated was Category 3 on the NHS Pathways triage system, with a response time of up to 2 hours. There was then a second call due to worsening symptoms and a further triage. The same information was relayed to a second call handler, that Daniel would not be able to answer the questions accurately due to his learning disability. The category remained at C3. There was a delay in paramedic arrival at the property, due to the Surge Level the service faced at the time. Further backup paramedic support was immediately required as Daniel’s condition had deteriorated significantly. The category was changed to C2 and then C1. Despite the intervention of the paramedics, Daniel died at the scene. Post-mortem examination has identified that the hiatus hernia had been obstructed and caused a gastrointestinal haemorrhage which resulted in hypovolemic shock which was the medical cause of Daniel's death. 2 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 could 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 NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage. (2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew. (3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur. 6 ACTION SHOULD BE TAKEN I understand that NHS Pathways telephone triage system is a clinical decision support system (CDSS) supporting the remote assessment of callers to urgent and emergency services. The system is owned by the Department and Health and Social Care, but is delivered by NHS Digital. I consider that together or individually you would have the ability to make any changes to the triage system. In my opinion action should be taken to prevent future deaths and I believe you and your organisations have the power to take such action. 3 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 July 2022. 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 South East Coast Ambulance Service, I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 7TH June 2022 4
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.
From Helen Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU Ms Katrina Hepburn Area Coroner, for the coroner area of Central & South East Kent Coroner Service Team Oakwood House Oakwood Park Maidstone ME16 8AE 4 April 2024 Dear Ms Hepburn, Thank you for your letter of 7 June 2022 to the Department of Health and Social Care, regarding the death of Daniel Ludlam. I am replying as Minister with responsibility for urgent and emergency care. Please accept my sincere apologies for the significant delay in responding to this matter. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ludlam’s death, and I offer my sincere condolences to his family and loved ones. It is of course vital that we take learnings where they are identified to improve NHS care and I am grateful to you for bringing these matters to my attention. The cause for concerns raised in the report were around the NHS Pathways triage system, and in particular for patients with a learning disability. I recognise that NHS Pathways is a system to assess a patient’s clinical presentation, and requires well trained and highly competent system users to elicit the most effective outcome for patients. I am aware that in her capacity as Clinical Director of NHS Pathway, NHS Digital, has provided a thorough response to your Regulation 28 report. I do hope that as an executive non- departmental public body, sponsored by the Department of Health and Social Care, the response has addressed each of your concerns to prevent future deaths. With reference to your first concern around the system not taking into specific account of patients who have not been able to understand questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis. NHS Pathways enables an assessment of a patient’s current clinical presentation along with the means to adapt the process where standard triage might not be appropriate, such as for patients with learning difficulties. ‘Early Exit’ is one of the elements of functionality that enables deviation from a standard triage with other options such as a route for patients with known health issues who have a care plan in place and the ‘not sure’ option where the caller hasn’t been able to give a definitive response despite probing. 1 You raised concerns about future callers with learning disabilities without a carer present to assist with the interpretation of the questions and to advocate on their behalf, in this case the protocol for the health advisor would be to ‘Early Exit’ and a clinician would take over the call. A clinician can then make a judgment, based on a framework of clinical accountability, about next steps for the patient. More broadly, I recognise the pressures A&E and ambulance services are facing. Last January we published our ambitious Delivery plan for recovering urgent and emergency care services to drive sustained improvements in urgent and emergency care waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours, including to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. Your report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. At a national level, we have seen significant improvements in performance this year compared to last year. In winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a reduction of nearly 25%. SECAmb average Category 2 response times were over 5 minutes faster compared to the same time period last year, a 16% reduction. I hope this response further reassures you of the work undertaken. Thank you for bringing these concerns to my attention. Yours, HELEN WHATELY
See every Prevention of Future Deaths report matching Emergency services related deaths (2019 onwards), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.