Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0100, written 22 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Mar 2023 |
|---|---|
| Reference | 2023-0100 |
| Deceased | Kenneth Adams |
| Coroner | Bredan Allen |
| Coroner area | Dorset |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | South Western Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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: 1. International Academics of Emergency Dispatch, Suite B, 4th floor, Spectrum, Bond Street, Bristol BS13LG 1 CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset 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 the 5th November 2021, an investigation was commenced into the death of Kenneth Michael Adams, born on the 21st August 1951. The investigation concluded at the end of the Inquest on the 9th March 2023. The Medical Cause of Death was: la Hypoxic brain damage lb Cardiac arrest le Profuse bleeding from a laceration of the scalp 2 Treatment with clopidogrel for stenosing atherosclerosis of carotid arteries The conclusion of the Inquest recorded that Kenneth Michael Adams died as a consequence of an accident to which a failure to provide emergency medical assistance in a timely manner more than minimally contributed. A failure .of the Medical Priority Despatch System to acknowledge and assess persistent bleeding from a scalp injury against a background of antiplatelet medication also possibly contributed to his death. 1 4 CIRCUMSTANCES OF THE DEATH At approximately 3.30am on 19th October 2021, Kenneth Michael Adams, who was prescribed clopidogrel and who lived alone at 60 Vernons Court in Bridport, which is supported housing provided by a housing association, suffered an accidental fall from a standing height, which resulted in a laceration to his scalp. At 4.06 am Mr Adams contacted the ambulance service to explain that he had fallen, injured his scalp and that he could not stop the bleeding. Mr Adams' call was triaged using the Medical Priority Despatch System, which resulted in a disposition of 17-b-01: fall possible dangerous area. This translated to a category 3 ambulance response. The national target set by the Department of Health is to attend category 3 incidents within 120 minutes on at least 90% of occasions (so by 6.13 am), with an average response time of 60 minutes (by 5.13am). At the time of this call, Mr Adams appeared well with no additional symptoms. Mr Adams had also activated his careline, which is an element of the support provided by the housing association. At 7.53 an operator from the careline contacted Mr Adams to check on his welfare. Mr Adams reported that he was now feeling sick, that he was wobbly when stood up and that his bleeding was continuing. The careline operator contacted the ambulance service and advised of the new symptoms. A further triage was conducted, with the same disposition of fall, possibly dangerous area being reached, as the algorithm being used failed to account for the persistent nature of the bleeding being experienced and that Mr Adams was prescribed clopidogrel. At 10.25 Mr Adams again spoke to a careline operator. He was by now slurring his words and his speech was noticeably slow. It is likely he was experiencing symptoms associated with hypovolaemic shock. If Mr Adams had received treatment by 10.25, he would have survived the injury he had sustained. The first ambulance resource arrived at Mr Adams' property at 11.56, by which time a neighbour had found Mr Adams when Mr Adams had called for his help. Mr Adams was conveyed to Dorset County Hospital, where despite treatment he died on 19th October 2021. 2 5 CORONER'S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. A patient, prescribed either anti platelet or anticoagulant medication, falling and sustaining a scalp laceration that is not "spurting or pouring blood" (the MPDS definition of "uncontrolled bleeding"), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not "spurt or pour" blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as "serious haemorrhage". Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a "serious haemorrhage", the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock. 3 2. I have concerns with regard to the following: i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient's predicament and the potential consequences of the continued blood loss. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your 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, 17th May 2023. 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: (1) Prince Evans Solicitors (solicitors for brother of Mr Kenneth Adams); (2) Browne Jacobson Solicitors (solicitors for South Western Ambulance Service NHS Foundation Trust); (3) Appello Limited I am also under a duty to send the Chief Coroner a copy of vour response. 4 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 Dated 22nd March 2023 Signed Brendan J Allen 5
3 responses 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.
International Academies of Emergency Dispatch & Priority Dispatch Corp UK Ltd Spectrum Bond Street Bristol BSl 3LG IAED of Emergency Dispatch. International Academies The Coroner's Office for the County of Dorset Civic Centre Bourne Avenue Bournemouth BH2 6DY United Kingdom 22th May 2023 Dear Sirs RE: Response Regulation 28 Report to Prevent Future Deaths - Kenneth Michael Adams Pursuant to the Coroner's Report received 29th March 2023 ( Academies of Emergency Dispatch encloses its response to the report. ), the International I wish to express my gratitude to your staff who assisted us by obtaining the necessary documentation from the South Western Ambulance Service NHS Foundation Trust, enabling the Academies to fulfill its due diligence to thoroughly review the case and respond accordingly. I wish also to thank you for agreeing to extend the deadline date while all the documentation was collected. If there are questions, or a follow-up is necessary please do not hesitate to contact me . Yours Sincerely, Priority Dispatch Project Coo1-di nam1- Leacl Summary: There were several compounding factors that contributed to the delayed EMS response in this case. First and foremost, the nearly eight-hour response is far beyond the CAT 3 standard assigned, and beyond any clinical or public expectation known to this reviewer. The SERIOUS Haemorrhage code suggested in the coroner's report is equivalent to the initial code assigned with regard to CAT 3. EMDs are trained to stay on the line while providing Dispatch Life Support instructions like bleeding control. This may have helped to stop the bleeding in this case, or at least alert the same EMD to the persistence of the bleeding. Instead, repeated calls to various EMDs from Careline, whose personnel were not at the scene, resulted only in inquiries about the patient's condition worsening, and the callers simply did not have this information. In times of high call volume, SWAST EMDs are instructed by local policy to provide Dispatch Life Support instructions and then utilize the Urgent Disconnect option in ProQA to end the call. This policy and practice does not ensure the instructions are carried out and does not allow for essential monitoring of conditions such as active bleeding. There was no productive follow-up to Careline's 3rd call to 999 after learning the patient's condition had apparently worsened . A voicemail was left at the patient's residence at 0806, but no other known action was taken. No ProQA Summary record was received for Careline's 2nd or 3rd call and there is no record of re-triage other than asking the 4th party caller if the patient's condition had worsened. This leaves significant gaps without a proper re triage between the pt and 4th calls (3hrs 44 min), and the 4th and 6th call (3hrs 45 min). A 4th call from Ca reline was received at approximately 1030 and the EMD was advised the patient was still bleeding, but an ambulance was still not dispatched until 1143 when a 2nd party caller from the residence advised the patient was not alert. A CAT 2 response was then assigned. Recommended Actions: 1. The IAED is currently implementing new language designed to better define the term SERIOUS Haemorrhage and structure the related Key Question in a way that persistent, uncontrolled bleeding is more definitively qualified as SERIOUS Haemorrhage. It is recommended that UK Ambulance Trusts educate EMDs that uncontrolled bleeding should be considered SERIOUS Haemorrhage until proven otherwise. 2. SWAST SOP VH45 v.2.1, MPDS Case Exit and use of Urgent Disconnect, Section 3.4 or 3.5 should be immediately amended to include uncontrolled bleeding and potentially pt Party alone patients as exceptions, and EMDs should be educated and encouraged to continually provide bleeding control instructions until bleeding control is achieved or responders arrive. Bleeding that persists after bleeding control instructions have been provided requires active management. 3. Repeat calls for assistance from a caller not on scene with the patient should be followed 5 up in a manner that ensures complete and accurate updates are received and instructions are carried out. EMDs should be encouraged to request 3rd or 4th party caregivers to make their way to the scene to conduct a proper, 2nd party re triage, closely monitor ist-party-alone patients, and carry out any instructions provided. Asking a 3rd or 4th party caller if the patient's condition has worsened should not, in and of itself, be considered an accurate or complete re-triage. 4. The IAED is currently studying the potential impact of the unique coding of patients who are taking anticoagulant/antiplatelet medication (blood thinners) who have active bleeding or closed head injuries. Due to the relatively high number of patients receiving this therapy* as compared to the number of patients who are at risk of a poor outcome related to that therapy, there is significant risk of over-triage, which may only make matters worse in areas with limited resources . Another consideration is that those patients who do not meet these criteria will inevitably suffer even longer wait times as a result . *Preliminary data suggests that nearly 22 percent of all patients with a chief complaint of hemorrhage are on blood thinners (30 percent of those aged 60-75 and 41 percent aged 75-90). Commentary: There are inherent risks associated with exceptionally long response times, no matter what the Chief Complaint may be. A patient appearing stable at the time of the first call may develop problems not associated with the Chief Complaint and such problems may be missed even when reassessed as those issues may not be apparent. All-to-common examples are complications of prolonged immobility or adverse environment or, as in this case, the inability of lone patients to accurately assess a problem or carry out basic instructions. And as additional codes are requested to prioritise patients at greater risk, with the dangerous assumption that the others can safely wait for extended and indefinite periods of time, more and more apparently stable patients are subject to developing additional problems associated with comorbidities or environment. It is apparent that an impactful lack of resources, rather than triage inefficiencies, is primarily responsible for these prolonged response times and, until this fundamental problem is appropriately addressed, patients will continue to suffer the consequences. Chair, Medical Council of Standards, IAED Academy Protocol Development ~TAED n ln1emallonal 1\ demies or Emcrgl.'.lw;y ()ispatch. 1 6
15 February 2024
Private and Confidential
Mr Darren Stewart OBE
Assistant Coroner for Surrey
SABP NHS Foundation Trust
18 Mole Business Park
Randall’s Road
Leatherhead
KT22 7AD
Woodhatch Place
11 Cockshot Hill
Reigate
RH2 8EF
Dear Mr Stewart
Barbara Woodman (deceased)
Regulation 28 Report to Prevent Future Deaths
Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey
County Council
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December
2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the
report carefully, together with senior officers within both organisations.
In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of
hours to provide timely and effective passage of information in relation to concerns for vulnerable
persons in the community.
The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to
inform services where they have had contact with an adult who is considered to be vulnerable and/or
at risk. It provides information to partner agencies and will often add to the information that the Trust
already holds about a person. This could inform further actions that might be taken by the Trust
which may include revisions to assessments or care plans.
A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The
Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s
may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals
Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by
Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This
allows emergency services to request critical information in an immediate timeframe to help inform
decisions about people they have come into contact with.
Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7
days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New
Page 1 of 2
Year. Any referrals or concerns from the police that require an immediate response there is a clear,
well known and well used process for officers, in that they must make contact with either the Emergency
Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a
SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable
for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140
contacts from the Police directly to them.
We work collaboratively with partner agencies to review and improve our joint working processes. In
relation to SCARF procedures, representatives from the Trust most recently met with Surrey County
Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review
of our cross agency SCARF process. As part of this consideration will be given as to how information
is shared between agencies and family/carers alongside issues of confidentiality and consent.
The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm,
carry out a screening process in respect of SCARF forms received. Appropriate action will then be
taken based on the information provided and the risk profile of the person this relates to.
In relation to your concern relating to the lack of a unified record keeping system allowing sharing of
patient information between different components of the NHS, including primary and secondary care
providers, you have also addressed the report to the Chief Executive of NHS England who will be best
placed to respond to this concern.
On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to
Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms
Woodman’s family that we have reflected on your concerns and provided reassurance as to our
processes.
Yours sincerely,
Chief Executive
Surrey and Borders Partnership
NHS Foundation Trust
Executive Director
Adults, Wellbeing & Health Partnerships
Surrey County Council
Page 2 of 2
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Hull City Council Response Summary Based on the identified risks from the coroner’s report relating to “Regulation 28: Report to prevent future deaths (1)” order to take action to prevent future deaths from occurring. On review the Highway Authority has identified the following preventative measures to be considered. These measures are listed below as Preventative numbers as categorised in the Coroner’s report and are in response to the coroner’s concerns to determine mitigation factors to all risks identified. Preventative actions HCC proposed to take: Action ref P1 Action description Relocation of the existing taxi ranks to Alfred Gelder Street. P2 P3 P4 P5 Timescales Action ref P1 P2 P3 P4 P5 Design of an increased width, all direction signalised crossing facility at Silver Street/Scale Lane Relocation of the existing crossing facility on Lowgate closer to Market Place Proposal to consider the viability of widening the footpaths on Lowgate between Silver Street and Alfred Gelder St Wider old town area, to be agreed, would become a 20mph zone and additional VMS signs would be installed at either end of the zone. Timescale Consultation already commenced, HCC is moving into design stage and will commence with legal orders, Summer 2023. This proposal is in feasibility stage, on receipt of traffic/pedestrian count data, a new design will be formally produced for consultation. Autumn 2023 Item included as part of P2 and will commence in coordination. Completion of feasibility Autumn 2023 20mph order and consultation Autumn 2023 All preventative measures denoted above will firstly undertake a full design review and feasibility study, the measures will then be carefully considered as options to mitigate concerns Additionally, to note, none of the measures are set out within the current Highway Capital programme and authorisation to proceed will need to be sought from the Portfolio Holder for Transportation, Highways and Roads. Funding is available to support the design and development of P1, P2 and P3. Additional funding for the remaining interventions would need to found or other schemes would need to be reprioritised. From the Regulation 28 Report there were 6no Coroners concerns identified that should be further addressed by the highways authority denoted below. (1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end. RESPONSE 01 – Mitigation identified in P1/P2/P3 HCC has further engaged with the Hackney Association with the request to relocate the taxi rank on a permanent basis removing stationary vehicles from Lowgate during the peak night-time economy hours, and during the day. HCC originally proposed a relocation of the rank to Scale Lane, but a response from the Hackney Association made recommendation to relocate the rank to Alfred Gelder St. HCC are promoting the suggested relocation to Alfred Gelder St and will take action to implement on completion of consultation, design, and any accompanying legal orders. In the last month the highway authority has procured and carried out investigatory works for counts of vehicle movements, pedestrian counts, and taxi link count surveys. On receipt of this new data HCC traffic engineers will work towards a feasibility study for a proposed road safety improvement scheme, with a strategic view of providing a new wide crossing facility to the junction of Silver Street and Scale Lane. This option will create a new dedicated crossing at this junction to improve pedestrian safety. Additionally, by relocating the existing crossing to Market Place will improve the pedestrian desire lines further south on Lowgate. (2) Police raised concerns as follows: - The road remaining open during a Friday and Saturday night. - The number of pedestrians using the area. - Many people in drink in the area having to cross the road. - The road is a 30 mph. - - The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians. Lights of vehicles are distracting RESPONSE 02 – Mitigation identified in P1/P2/P3/P5 The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity to the A63, the proposals to improve pedestrian safety in the preventative measures as listed above would negate any requirement for a full road closure and the relocated taxi stand would remove taxis from Lowgate further mitigating 3 point turns in carriageway. Additionally, 3-point turns has been raised with the Hackney Association and it was agreed this would be cascaded to all drivers to cease this manoeuvre on Lowgate. HCC are progressing the option of reducing the speed limit in the old town wider area to 20mph, with additional VMS signs at either end of the zone as response to improve safety. (3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”. RESPONSE 03 – Mitigation identified in P1/P2/P3/P4 A feasibility study has commenced with a view to widening the footway which will ameliorate pedestrian safety. The feasibility study will also include consideration of a slight realignment of the carriageway to provide additional physical traffic calming measures to motorists, The decreased road widths will create an additional preventative measure with the purpose of preventing vehicles stopping on Lowgate. Consultations with the Hackney Association to relocate the taxi rank away from Lowgate will reduce vehicle movement, the feasibility study includes a dedicated crossing facility and reduced speed limits as identified in response 01/02. (4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street. RESPONSE 04 – Mitigation identified in P1/P2/P3/P4 The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity of Lowgate to the A63, additionally the proposals to improve pedestrian safety in the preventative measures denoted above would negate any requirement for a road closure. (5) I note the statement from the local authority listed - They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles. - The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets. - That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this. - The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated. - Crossing facilities had been looked at but could not be positioned within a suitable distance. RESPONSE 05 – Mitigation identified in P1/P2/P3/P4 The Highways Authority will be progressing a review of the speed limits within the city centre. Ahead of any wider review Lowgate has been identified as a priority and further consultation will be carried out and meeting minutes taken to identify the key decisions as evidence. Consultation with Hackney association is ongoing, and agreements will be evidenced. The road closure will not be pursued given the preventative measures itemised in this response are deemed as satisfactory mitigating factors. The crossing facilities have been reviewed and are now identified as a project under feasibility study, the item above can now be satisfied after further review of relocation existing crossing as identified in P4 (6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will occur. RESPONSE 06 – Mitigation identified in P1/P2/P3/P4 The Highway Authority has reviewed the coroners concerns and has identified suitable mitigation measures to address the concerns raised and risks identified and reduce the likelihood of future incidents and severity of outcome.
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