Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0325, written 12 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Sep 2023 |
|---|---|
| Reference | 2023-0325 |
| Deceased | Rashdah Bhatti |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Wales prevention of future deaths reports (2019 onwards) · 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.
John Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 4 Welsh Ambulance Services NHS Trust, Ty Elwy, Unit 7 Richard Davies Road St Asaph Business Park, St Asaph, Denbighshire LL17 0LJ CORONER I am John Gittins, Senior Coroner for North Wales (East and Central) 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. INVESTIGATION and INQUEST On the 16th of June 2022 an investigation was commenced into the death of Rashdah Waseem Begum Bhatti (DOB 19/05/45) who died at her home in Prestatyn on the 14th of June 2022. The conclusion of the inquest on the 11th of September 2023 was by way of a narrative conclusion in the following terms : “On the 14th of June 2022 at her home, the deceased began haemorrhaging from her varicose veins and although ambulance assistance was requested, there were no resources available to respond for some hours. This resulted in a delay which denied Mrs Bhatti timely and potentially life preserving treatment and she was pronounced dead at the scene at 21.15 hours” CIRCUMSTANCES OF THE DEATH As detailed in the narrative conclusion the deceased began bleeding from varicose veins and the extent of the haemorrhage was exacerbated by her being on anticoagulants. An initial 999 call was made at 18.25 and over the course of the next two hours there were a further six calls made before a response was allocated, with the first ambulance arrival on scene at 20.36. 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. – Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN | The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object” Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased. Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway. 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 7th November 2023. I, John Gittins, 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 Family of the Deceased and to the Chief Coroner. 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 Dated 12th September 2023 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN |
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.
Swyddfa’r Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services Office 6 November 2023 PRIVATE & CONFIDENTIAL Mr J Gittins Senior Coroner – North Wales (East and Central) Dear Mr Gittins, Re: Rashdah Waseem Begum Bhatti I write in response to the Prevention of Future Deaths Report issued to this Trust on 12 September 2023, following the inquest in relation to Rashdah Waseem Begum Bhatti. The matters of concern that you have asked the Trust to consider are: “The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object” Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased. Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway.” Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.wales.nhs.uk Pencadlys Rhanbarthol Ambiwlans Regional Ambulance Headquarters Beacon House William Brown Close Llantarnam, Cwmbran NP44 3AB Ffôn/Tel 01633 626262 The Medical Priority Dispatch System™ (MPDS®) establishes a universal standard for emergency dispatchers taking calls for a broad range of triage response which may include drowning, stabbing, gunshot wounds, and much more. Tested over hundreds of millions of calls since 1979, MPDS includes 36 protocols that are continually updated as per recommendations and research made by specialist medical professionals and associations. Accredited Centre of Excellence (ACE) designation is reserved for high-performing agencies that consistently achieve excellence. It is a distinguished award for those who cultivate a centre wide pride, teamwork, and innovation by putting their communities first. I also attach for your reference copies of WAST ACE Performance standard data and the Agency Performance Benchmark, both providing details of the MPDS audits undertaken over a 24-month period. These documents illustrate that the Trust is performing to an ACE level in relation to all aspects of our call handling. The audits include a review of the Post-Dispatch Instructions (PDIs) which includes the advice that should have been given with regard to Mrs Bhatti’s leg. Whilst referred to as “Post-Dispatch instructions”, these instructions are given at the time of the call, whether a resource has been dispatched or not. I also attach a copy of the MPDS call audit data, for audits completed in the last 24 months in relation to protocol 21(Haemorrhage/laceration). As you will see from that data (WAST Agency Performance document), of the 363 PDIs audited, errors occurred on 16 occasions. During October 2023 we undertook a focused audit of calls in relation to protocol 21(Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss. Yours sincerely, Chief Executive Enclosures: WAST_ACE_Performance_Benchmark WAST_ACE_Performance_Standard WAST_Agency_Performance_24 months
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