Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0294, written 14 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Aug 2023 |
|---|---|
| Reference | 2023-0294 |
| Deceased | Leonard King |
| Coroner | Sean Cummings |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 4 , Executive Officer - Association of Ambulance Chief Executives , Chief Executive Officer - Royal College of Emergency Medicine , Chief Executive Officer - Royal College of General Practitioners , Chief Executive Officer – Urgent Health UK 1 CORONER I am Sean CUMMINGS, Assistant Coroner for the coroner area of Milton Keynes 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 12 May 2022 I commenced an investigation into the death of Leonard Jomo Isaac KING aged 37. The investigation concluded at the end of the inquest on 25 April 2023. The narrative conclusion of the inquest was that: Mr Leonard Jomo Isaac King died at Milton Keynes University Hospital on the 4th May 2022 after collapsing with a hypoxic cardiac arrest consequent on blockage of his airway because of epiglottitis. There was a missed opportunity to recognise and escalate his case at the Milton Keynes Urgent Care Centre on the 2nd May 2022. There was a further missed opportunity by South Central Ambulance Service when they were called via 999 to his home on the 2nd May 2022 later that day afternoon, to recognise the fact that he was in a precarious position and removing him to the ED. This was an avoidable death. 4 CIRCUMSTANCES OF THE DEATH Mr Leonard Jomo Isaac King died at the Milton Keynes University Hospital on the 4th May 2022 as a result of a hypoxic cardiac arrest secondary to an obstructing epiglotittis. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Acute epiglottitis, also known as supraglottitis, is an infection of the tissues of the epiglottis and surrounding tissue that has potential to cause a sudden, complete and fatal obstruction to the airway. Prior to mass immunisation of children against Haemophilus Influenzae the disease was predominantly confined to young children. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis. It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis. The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring. Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Prompt recognition and treatment is lifesaving. Education and training in the movement of epiglottitis into the adult population may assist in recognition and early treatment. 6 ACTION SHOULD BE TAKEN In my opinion 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, namely by October 10, 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 - - Milton Keynes Urgent Care Centre South Central Ambulance Service - Family of Mr King 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 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 by the Chief Coroner. 9 Dated: 15/08/2023 Sean CUMMINGS Assistant Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 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.
Association of Ambulance Chief Executives 25 Farringdon Street London EC4A 4AB 4 October 2023 Sean Cummings Assistant Coroner for Milton Keynes Dear Mr Cummings LEONARD JOMO ISAAC KING (DECEASED) I am writing in response to the preventing future deaths report we received at the Association of Ambulance Chief Executives (AACE) dated 15th August 2023, and I respond as our Managing Director on behalf of the AACE. It may be helpful for us to explain that AACE is a private company owned by the English and Welsh Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub- groups. With regard to your matter of concern relating to ambulance services: Education and training in the movement of epiglottitis into the adult population may assist in recognition and early treatment. With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. We currently have guidance for children with suspected epiglottitis but not for adults. We had already started to scope and develop new guidance for ambulance clinicians on rarer and specific conditions that need pre-hospital clinical assessment and management that differs from standard practice. We appreciate the importance of the prompt recognition or suspicion of suspected epiglottitis in adults and that typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Therefore, as part of this new guidance we will include adult epiglottitis as one of the conditions and include the key assessment and management points and the importance of rapid conveyance to hospital for lifesaving treatment. AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors at our next meeting. We will suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required. We will also share the report with education leads of ambulance trusts, via the national education network for ambulance trusts. On behalf of AACE, I would like to extend our sincere condolences to the family of Leonard Jomo Isaac King. I hope this response has adequately addressed the concerns that you have raised. If you have any further questions please do not hesitate to get in touch. Yours sincerely Managing Director
24 August 2023 15:01 [EXT]FW: Coroner's Regulation 28 Report (MD/ND Forum info) Reg 28 Report - After Inquest KING L J I 04052022.pdf; FW: Coroner's Regulation 28 Report (MD/ND Forum info); Coroners Regulation 28 Report (attention MDs/NDs) ) From: Sent: To: Cc: Subject: Attachments: Dear Thank you for the Regulation 28 Report. On behalf of Conor Burke CEO UHUK, I have arranged for all Medical Directors and Nurse Directors of our 30 members to receive a copy of the Report and asked them to distribute it to their front line clinicians using their standard communication mechanisms (attached emails) . These clinicians provide care to 65% of the UK population. In addition the report will be reviewed and discussed at the Medical Directors and Nurse Directors Teams Meeting to be held on 18th September 2023, 1-2pm. I trust that this meets your requirements. Please do not hesitate to contact me for any further information. Kind regards, FRCGP MRCP MD GP Lead Great Homer St Medical Centre | 49-51 Mere Lane, Liverpool, L5 0QW | Part of Anfield/Everton Primary Care Network Chair Urgent Health UK Delivering the best possible health outcomes through Social Enterprise Follow us on LinkedIn 1
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