Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0183, written 9 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2023 |
|---|---|
| Reference | 2023-0183 |
| Deceased | Sandra Finch |
| Coroner | Emma Serrano |
| Coroner area | Stoke on Trent and North Staffordshire |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | West Midlands Ambulance Service University NHS Foundation 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England; and 2. West Midlands Ambulance Service 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of the South Staffordshire. 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 9th October 2021, I commenced an investigation into the death of Ms Sandra Diane Finch. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect. The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation CIRCUMSTANCES OF THE DEATH 4 i) Sandra Diane Finch was 44 year old woman who had a history of Type 1 diabetes mellitus. She used an insulin pump to administer insulin and had done so since 2005. ii) She had recently had a dental procedure and was also recently prescribed antibiotics for an infection. It was accepted by clinicians that this can cause a Type 1 diabetic to need more insulin than they would normally need. iii) On the 3 December 2021, Sandra Diane Finches glucose levels start to rise. This is picked up by the pump that she used and this sounded regular alarms and gave correctional doses of insulin. iv) On the 4 December 2021 Sandra Diane Finch called the West Midlands Ambulance Service and told them she was feeling more sleepy, her glucose was high and she had been vomiting. The categorisation of this call was category 3. This meant she was a medical emergency and required an ambulance. However, before an ambulance could be dispatched a clinical review Was required by the CV team. v) The team was under staffed and had no time limit attached for an assessment. As such, an attempt for an assessment did not take place until 10 hours later. At 7:22 a call was made to Miss Finch. This was 1 [IL1: PROTECT] unanswered. The options available, at this stage, would have been to dispatch an ambulance, or to place the call back, back into the CV Teams work load. This was what happened. vi) At 12:47 on the 5 December 2023 the decision was made by the team to categorise the ambulance request as a category 2 and dispatch an ambulance. This arrived at Sandra Diane Finches address at 13:08 and she was found to have passed away as a result of ketoacidosis. vii) Clinical opinion disagreed that category the correct categorisation. It should be have been a category 2. Evidence was heard that the pathway had to be followed rigidly so a computer could decide the category, but accepted that a clinician listening to the answers may well have made a different decision and given the call a category 2 marking. three was viii) The view of clinicians was that had the ambulance been despatched within the accepted time limit for a category 3 ambulance, Sandra Diane Finch would not have died when she did. 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. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. 2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 27 June 2023. 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. West Midlands Ambulance Service; 2. NHS England; 2 [IL1: PROTECT] 3. Medtronic Ltd; and 4. Family of Sandra Dianne Finch 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 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 9 May 2023 Miss Emma Serrano Area Coroner Stoke on Trent and North Staffordshire 3 [IL1: PROTECT]
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.
7 June 2023 Ms Serrano Assistant Coroner for South Staffordshire Judges Chambers County Buildings Martin Street, Stafford ST16 2LH Dear Ms Serrano Re: Regulation 28 Report to Prevent Future Deaths – Sandra Diane Finch (Deceased) Thank you for your email dated 15 May 2023 attaching your Regulation 28 Report. Firstly, I am sorry that you have had to raise concerns with West Midlands Ambulance Service University NHS Foundation Trust (WMAS) following the inquest of Mrs Finch. Can I please take this opportunirty to pass on my sincere condolences to the family of Mrs Finch. Please see our response to your concerns. Concern 1 That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. Response The Department of Health guidelines require UK ambulance Trusts to use one of two triage tools approved for assessing 999 ambulance calls. West Midlands Ambulance Service University NHS Foundation Trust triage all 999 calls using NHS Pathways. NHS Pathways determines the most appropriate level of care for the presenting symptoms during the call. Patients requiring an emergency ambulance are triaged into four categories, with an associated mean average response timeframe for each. The symptom groups within those categories are determined by the Clinical Coding Review Group, consisting of senior representation from all UK ambulance trusts. The ambulance response categories and timeframes (hh:mm:ss) are: Category 1 (00:07:00): A time critical, life-threatening event needing immediate intervention or resuscitation. For example, cardiac or respiratory arrest, airway obstruction, ineffective breathing, and unconsciousness with abnormal noisy breathing. Category 2 (00:18:00): Potentially serious conditions that may require rapid assessment, urgent on scene intervention and or urgent transportation. For example, stroke, heart attack, severe blood loss and trauma. Category 3 (01:00:00): An urgent problem that needs treatment to relieve suffering and transportation, or assessment and management on scene, or assessment, treatment, and referral to an alternative care provider where necessary within a clinically appropriate timeframe. For example, conscious patients presenting with a medical emergency, traumatic injuries, to include falls. Category 4 (90th percentile 03:00:00): Problems that are not urgent, may be managed within the home (see & treat) or may require transport within a clinically appropriate timeframe. For example, falls with no declared injury. When reviewing the 999 call made by Mrs. Finch, a higher response category would not have been generated without further clinical intervention. Mrs. Finch was conversant and advising her blood sugars were probably high due to being a type 1 diabetic. When asked, Mrs. Finch was unable to test her blood glucose level due to being unable to locate her testing kit, she was struggling generally with day-to-day activities and felt sleepy. The call assessor advised Mrs. Finch that she may receive a call back from a clinician for further assessment. Concern 2 That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays. Response In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category 3 and 4 incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments. From this period the Trust continued to experience a considerable number of lost operational hours through delays in hospital handover, combined with increased in staffing abstractions due to sickness and covid isolation requirements. This, combined with the positive outcomes for patients, lead to the clinical validation team becoming a substantiated process within the Trust. All category 3 and 4 incidents, except for a predefined list of exemptions now go directly to the clinical validation team. The team undertake a clinical triage, supported by the NHS Pathways triage tool for clinicians, to determine the most appropriate outcome for the patient based upon their clinical knowledge and experience. Outcomes range from a higher ambulance response category, referrals into urgent and community services, and self-care advice. By appropriately reducing the requirements for emergency ambulances, this supports greater availability of emergency resources to those patients with the most acute needs. All patients presenting for clinical assessment are risk assessed by a senior clinician called the clinical navigator. The clinical navigator, based upon the initial triage, determines if the patient is safe and appropriate to wait for clinical assessment. Those patients deemed unsuitable for clinical assessment are presented to dispatch for the next available ambulance resource, dependent on their category. The clinical navigator does have autonomy to upgrade incidents, should this be indicated; no patient is to be left waiting unnecessarily. The Trust now aims to contact category 3 and 4 patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator. All clinicians, and the clinical navigators, receive regular clinical audit to ensure competency, and safe and appropriate outcomes for patients. Audit is a requirement of NHS Pathways licensing agreement and provides learning opportunities for both the individual clinician and the Trust. All serious incidents and concerns raised regarding the appropriateness of a clinical triage receive audit and senior review. Throughout 2023-23, the clinical validation team reviewed 179,695 category 3 and 4 patients. 64% of patients were referred to alternative services or provided with self-care advice to manage their symptoms at home. When reviewing the last 6 months to May 2023, only 9.9% of patients referred to alternative services or given self-care advice recontacted the Trust through 999. Often, the reason for recontacting was due to a failed referral pathway and not through worsening symptoms. May I once again please pass on my sincere condolences to the family of Mrs Finch. I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report. If you require any further assistance, please do not hesitate contact me. Yours sincerely Chief Executive Officer
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