Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0064, written 7 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2024 |
|---|---|
| Reference | 2024-0064 |
| Deceased | Brian James |
| Coroner | Patricia Morgan |
| Coroner area | South Wales Central |
| Category | Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (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.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
ANNEX A
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:
WELSH AMBULANCE SERVICE NHS TRUST
1
2
CORONER
I am Patricia Morgan Area Coroner, for the coroner area of South Wales 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 5 November 2021 I commenced an investigation into the death of Brian JAMES . The
investigation concluded at the end of the inquest on 11/01/2024. The conclusion of the
inquest was Mr James died following a fall at his home. A delay in ambulance response
and admission may have affected the treatment available to Mr James.
3
Medical Cause of Death:-
1a Cerebral Haemorrhage Following Fall
1b
1c
II
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
CIRCUMSTANCES OF THE DEATH
These were recorded as :-
4
5
Brian JAMES aged 91 years suffered a Cerebral haemorrhage following fall at home. He
lived at home with his brother. He got up in the night to pass water due to his overactive
bladder and fell out of bed. He hit his head ( suffered abrasion) he did not lose
consciousness and was alert and talking when police and fire came to assist as his
brother could not get him back into bed. Ambulance was contacted however there was a
delay of around 9 hours until their arrival.
Ambulance crew came to do a courtesy visit the following morning and he was found in
bed GCS 3 and covered in his own vomit. CT head showed cerebral haemorrhage.
CT head findings discussed with neurosurgeons who said this man would not be for
surgical intervention
He sadly passed away in hospital on 1st November 2021.
The Inquest focused upon:-
(i) The events of 30 October 2021 and leading to admission
(ii) whether any delay in admission to hospital and medical treatment was causative
(more than minimally contributory) to death.
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) A script used by Operators within WAST as part of the Clinical Safety Plan inform
callers not to call back for an estimated time of arrival of the ambulance. They are told to
only call back if there is a deterioration in the patient’s condition.
(2) During periods of a delayed response from an ambulance, WAST best practice is for
an Operator to maintain regular contact with callers to assess any change in their
condition. During periods of excessive demand, it is considered that this is not always
achievable, and therefore Welfare calls are prioritised to callers considered vulnerable.
(3) There may be a risk that callers do not understand the instruction to only call back if
there is a deterioration, and/or may not recognise a deterioration, and feel they cannot
call WAST again. There is a further risk that unless regular welfare calls are made during
periods of delayed response, there is a missed opportunity to properly re-assess and re-
grade the response to a call by WAST.
6 ACTION SHOULD BE TAKEN
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 4 April 2024. 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.
COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
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.
7 February 2024
SIGNED:
Patricia Morgan Area Coroner for South Wales Central Coroner Area
7
8
9
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
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.
Cadeirydd Prif Weithredwr Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office Our Ref: ID 343 4 April 2024 PRIVATE & CONFIDENTIAL Patricia Morgan Area Coroner for South Wales Central By e-mail only: Dear Ms Morgan Re: Mr Brian James I am writing in response to the Prevention of Future Deaths Report issued to this Trust on 7 February 2024, following the Inquest. The matters of concern that you have asked the Trust to consider are:- 1. A script used by Operators within WAST as part of the Clinical Safety Plan inform callers not to call back for an estimated time of arrival of the ambulance. They are told to only call back if there is a deterioration in the patient’s condition. The current Emergency Medical Dispatcher call script within the Clinical Safety Plan (in escalation) informs the patient/caller not to call back to check the estimated arrival time of the ambulance. Prior to this and as part of Medical Priority Dispatch System, a first party caller (a patient caller) is informed ‘If anything changes, call us back immediately for further instructions’ and a second party caller (not a patient caller) is instructed ‘if s/he gets worse in any way, call us back immediately for further instructions. 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.nhs.wales Anfonwch unrhyw ohebiaeth i'r cyfeiriad canlynol:- Please forward any correspondence to the following address:- Beacon House William Brown Close Llantarnam Cwmbran NP44 3AB Ffôn/Tel 01633 626262 The Clinical Safety Plan is currently being reviewed. As part of this review, the Emergency Medical Dispatcher call script in escalation is being changed and the instruction not to call back to check the estimated arrival time of the ambulance is being removed. Instead, the caller will be reminded to call back if anything changes/they get worse. The review is currently in progress and the document needs to go through the relevant governance for internal approvals. 2. During periods of a delayed response from an ambulance, WAST best practice is for an Operator to maintain regular contact with callers to assess any change in their condition. During periods of excessive demand, it is considered that this is not always achievable, and therefore Welfare calls are prioritised to callers considered vulnerable. The Managing Delayed Response Standard Operating Procedure sets out a process to undertake welfare calls for those patients who are waiting a prolonged time for a response due to high demand. It is identified that it is best practice to maintain regular contact with patients who are experiencing a protracted response, but it is recognised that there may be limited capacity to undertake welfare calls due to high demand. Call takers’ priority is to take incoming emergency calls to identify patients who are sickest to ensure an appropriate response. Where capacity issues mean that a welfare call cannot be undertaken, this is documented within the incident. Callers are instructed to call back if anything changes/they get worse as covered in the above point. Emergency Medical Service Coordination is currently in the process of undergoing a restructure which will include a support role for dispatch. Whilst job descriptions, roles and responsibilities are yet to be confirmed, undertaking welfare calls will form part of the day-to-day responsibilities of this role. Additionally, the Trust is exploring new ways using technology to ensure the provision of welfare calls to patients waiting in the community and is liaising with other UK ambulance trusts to understand if there are any different processes in place which would be suitable for this Trust’s development and use. 3. There may be a risk that callers do not understand the instruction to only call back if there is a deterioration, and/or may not recognise a deterioration, and feel they cannot call WAST again. There is a further risk that unless regular welfare calls are made during periods of delayed response, there is a missed opportunity to properly re-assess and re- grade the response to a call by WAST. Please see the responses above I hope that the above responses fully address the concerns that you have raised, please do not hesitate to contact me should you require any further clarity. 2 May I also take this opportunity to again offer my sincere condolences to Mr James’s family on their sad loss. Yours sincerely Chief Executive 3
See every Prevention of Future Deaths report matching Emergency services related deaths (2019 onwards), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.