Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0422, written 31 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2023 |
|---|---|
| Reference | 2023-0422 |
| Deceased | Shiya Collins |
| Coroner | Georgina Nolan |
| Coroner area | Newcastle and North Tyneside |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | The Newcastle upon Tyne Hospitals 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. Managing Director, Cleric 1 CORONER I am Georgina Nolan, Senior Coroner for the coroner area of Newcastle and North Tyneside. 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 30th April 2022 I commenced an investigation into the death of Shiya Jonathan Barnard Collins, aged 23. The investigation concluded at the end of the inquest on 27th October 2023. The medical cause of death was 1a) Haemorrhagic hypovolaemic cardiac arrest; 1b) An incised wound to the right lower limb. 4 CIRCUMSTANCES OF THE DEATH Shortly after 10pm on the evening of 29th April 2022 Shiya Jonathan Barnard Collins kicked the glass panel of a door which cracked and caused a laceration to his leg. An ambulance was requested shortly before 10.30pm but the highest priority response (Category 1) was not generated. Further calls to the ambulance service were made but the computer system precluded clinicians from being able to upgrade the category of call despite information indicating that Shiya Collins was suffering significant blood loss and his clinical condition was deteriorating. The paramedic arrived 45 minutes after the first 999 call was made. By that time Shiya Collins had sustained catastrophic blood loss which caused him to suffer a cardiac arrest from which he could not be revived. 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) Seven calls were made to the North East Ambulance Service (following the initial call) indicating that Shiya Collins’ condition was deteriorating. Call handlers recognised the need for clinical input in order to facilitate a possible upgrade of the ambulance response to category 1. However, the locking facility on the Cleric computer system used in the control room precluded any clinician from assessing/upgrading the call because the system was locked and unable to be accessed whilst live calls relating to the case were ongoing. 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. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days, namely by 26th December 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: Mr Collins’ family, North East Ambulance Service, Newcastle upon Tyne Hospitals NHS Trust. 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 [DATE] [SIGNED BY CORONER] 31st October 2023 2
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.
STRICTLY PRIVATE AND CONFIDENTIAL Georgina Nolan His Majesty’s Senior Coroner for Newcastle upon Tyne and North Tyneside Civic Centre Barras Bridge Newcastle upon Tyne NE1 8QH Date: 22nd November 2023 Dear Georgina Nolan, INQUEST INTO THE DEATH OF MR SHIYA COLLINS Regula�on 28. Report to prevent future deaths. I am wri�ng to you as Technical Director of Cleric Computer Services Ltd and in response to the Regula�on 28 report for the preven�on of future deaths dated 31st October 2023 as issued by you following the inquest into the tragic death of Mr. Shiya Collins. The Coroner’s Concerns raised the following MATTERS OF CONCERN “(1) Seven calls were made to the North East Ambulance Service (following the ini�al call) indica�ng that Shiya Collins’ condi�on was deteriora�ng. Call handlers recognized the need for clinical input in order to facilitate a possible upgrade of the ambulance response to category 1. However, the locking facility on the Cleric computer system used in the control room precluded any clinician from accessing/upgrading the call because the system was locked and unable to be accessed whilst live calls rela�ng to the case were ongoing.” MY RESPONSE I address the point you have raised below: - Your concern relates to the Record Locking func�on with the Cleric computer system used by the North East Ambulance Service NHS Founda�on Trust (NEAS). I am extremely disappointed with the findings of the inquest and the subsequent regula�on 28 report directed towards Cleric. It appears that full explana�on of the system’s behavior along with the facili�es built in to mi�gate the situa�on outlined in the Regula�on 28 report have either not been fully disclosed, or they have not been set out clearly and in a comprehensible way. Record locking is a fundamental part of a mul�user system; the func�on serves to protect the integrity and consistency of data, without record locking there would be the risk of mul�ple users overwri�ng each other’s input. To overcome the effect of record locking the Cleric system has robust built-in mi�ga�ons, in the system operated by the North East Ambulance Service NHS Founda�on Trust the system had (at all material �mes) the following facili�es in place: All informa�on rela�ng to a call is visible/accessible even when a record (call) is locked. It is indicated as being in a ‘read only state’. Any user viewing a record (call) in a locked state would automa�cally have an up-to-date view of the call as the record is refreshed when data is added/removed/updated. Cri�cal informa�on rela�ng to the dispatch of an ambulance response can be updated while a record (call) is locked. This informa�on is clearly presented to the dispatch team. This informa�on may relate to and highlight the urgency/cri�cality of a response. The priority of the call can be upgraded while the record (call) is locked. This is restricted by role-based access and would normally be undertaken by a clinician. This updated informa�on is clearly presented to the dispatch team. Cri�cal informa�on rela�ng to the call can be entered and automa�cally sent to the responding crew(s) while the record (call) is locked. Addi�onal notes can be entered while a record (call) is locked. There is a mechanism available to create a note on the record (call) and send an alert to the user(s) responsible for that call (dispatch team etc), this is available while the record (call) is locked. A user who is ‘locked out’ and in the ‘read only’ view can request the ‘locking’ user to unlock the call via a system mail func�on in order that they can take control of the record (call). Record (call) locks can be forcibly removed by users of the system who have the appropriate role-based access. This would then allow another user to ‘take control’ of the record (call) in an unlocked state. The clinician could have created a new record (call) in isola�on to the original locked record (call) and triaged it appropriately. The lock feature is important to protect the integrity of the call and to stop data conflicts, the record (call) is only locked to an operator while they are ac�ve in the call. While it is technically correct that a clinician is not able to re-triage a call whilst it is in a locked state, I hope that the informa�on I have provided adequately addresses the concern that ‘the computer system precluded any clinician from accessing/upgrading the call because the system was locked” Within the capabili�es and provision of the Cleric system there are several means through which the ‘locking’ issue was able to have been overcome.(described above). I am concerned that the extent of the system mi�ga�ons in rela�on to the locking process were not fully conveyed during the hearing of the inquest. ‘Cleric’ systems handle millions of calls safely and effec�vely annually across the UK. We are constantly working in partnership with our customers (Ambulance Trusts) to ensure that the system evolves to meet the ever-changing demands placed on those customers. PROPOSED ACTION We have consulted with our customers (Ambulance Trusts) to explore poten�al improvements and we have agreed that minor changes will be implemented within the system: A record will open to a user in a ‘read only’ state. The user will then be required to request a lock on the record rather than the lock being applied automa�cally. The mechanism to request a release of a lock from one user to another user will be streamlined. It is important to note that the above changes will not eliminate locks as they remain a fundamental mechanism within these types of system, they are minor amendments to streamline exis�ng func�onality. System users also have robust opera�onal processes/procedures in place to handle such circumstances. This is a truly tragic case, and our thoughts are with Mr Collins’ family & friends. I hope that this addresses the maters of concern which you have highlighted. If we can be of further assistance to you then please do not hesitate to contact me. Yours sincerely Director
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