Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2024-0095, written 27 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2018 |
|---|---|
| Reference | 2024-0095 |
| Deceased | Kevan Funnell |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | West Sussex, Brighton and Hove |
| Category | 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.
VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC __ GILVA D.J.TISSHA W, BA(LAW)HONS ' THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 ' 1 2 3 4 5 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. 2. 3. , Head of Legal Service, South East Coast Ambulance ·Service , Emergency Operations Centre Manager, South East Coast Ambulance Service , Chief Executive, South East Coast Ambulance Service CORONER I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove CORONE~SLEGALPOWERS 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 10th November 2017 I commenced an investigation into the death of Kevan FUNNELL. The investigation concluded at the end of the inquest on 14th February 2018 .The conclusion of the inquest was ACCIDENT CIRCUMSTANCES OF THE DEATH See Record of Inquest CORONE~SCONCERNS 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 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CA THARlNE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FR( __ GILV A D.J.TISSHA W, BA(LAW)HONS THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRlGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00: 51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term "abandoned" however, it seems to me that that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were corning and goitl.fl about their 2 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARlNE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FR( __ GILVA D.J.TISSHAW, BA(LAW)HONS THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. explained that during each shift a I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ACTION SHOULD BE TAKEN 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 st May 2018. 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 . 3 VERONICA HAMILTON-DEELEY DL, LLB. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FR( __ GIL VA D.J.TISSHA W, BA(LAW)HONS THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 1. 2. Brighton and Hove Clinical Commissioning Group, 3. Care Quality Commission, 4. Secretary of State for Health, Department of Health 5. , Chief Executive, NHS England I am also under a duty to send the Chief Corone·r 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 Date: 2th February 2018 SIGf~~~~- Senior Coroner B r igh~ 4
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.
South East Coast Ambulance Service NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust Nexus House Gatwick Road Crawley RH10 9BG Mrs V Hamilton-Deeley HM Senior Coroner for Brighton and Hove The Coroner's office Woodvale Lewes Road Brighton BN2 3QB 30 April 2018 Dear Madam Re: Mr Kevan FUNNELL - response to Regulation 28 report Thank you for your letter of 27 February and attachments. I am very sorry that the care provided to Mr Funnell fell below the standards we strive to achieve. I have carried out an investigation into the concerns you have raised and set out my findings below. Following your Inquest, we arranged a second audit of the original 999 call. This was found to be non-compliant. One of our senior auditors, a registered Paramedic, has reviewed this call and believes that the consciousness level of Mr Funnell could be judged differently by the description provided, and so this is likely to be why the two audits reached different conclusions. As a clinician, she would have probed further to clarify the precise level of consciousness. The second call (at 2354 on 22.10.17 and not at 0016 on 23.10.17 as previously thought) has also been audited. This call was taken by the same call taker as the first and was also found to be non-compliant on the basis that the call taker should have probed further regarding Mr Funnell's bleeding, temperature and level of consciousness. The findings of both audits have been fed back to the person concerned for individual reflection and learning. I can confirm that there are adequate provisions in place, which provide for call takers to upgrade a call where the patient is in an unsafe public place (including when this relates to weather conditions) and to seek advice if they are concerned about the disposition reached. Yo1Ar serviu, U01AY c,C4.,H For Mr Funnell, the call taker did not seek to upgrade the call. This was human error. The manager of the Emergency Operations Centre (EOC) has used the learning from this case to remind all call takers about the circumstances to consider when upgrading a call and the need to seek senior guidance if there is any doubt about the disposition reached through NHS Pathways. As I believe you are aware, NHS Pathways is a national triage system used by half of the ambulance services in England. It is under constant review and direction by the National Clinical Governance Group, which comprises NHS clinicians with extensive experience in the urgent and emergency care services. On 22 November 2017, we implemented a significant update to NHS Pathways. The new version includes amendments to the supporting information for conscious patients, in order to try and make it more robust and easier for call takers in situations like this one, to identify consciousness levels. If this updated version had been in use in October 2017 then Mr Funnell would have been classified as unconscious. The disposition would therefore have most likely been a Red 2 response with a target attendance time of 8 minutes. This demonstrates the evolving nature of the Pathways system. In March 2018, there was a meeting between NHS Pathways and the ambulance trusts who use the system. NHS Pathways requested that all reports made by a Coroner, in which concern is raised about the use and application of NHS Pathways, are shared with them so that any recurring issues and trends can be identified and action taken. In your report, you raise concern about the delay in the ambulance attending. I can confirm that on 22 and 23 October 2017, we were experiencing delays in handing over patients to both the Royal Sussex County Hospital in Brighton and the Eastbourne District General Hospital. Hospital handover delays has a very significant adverse impact on our ability to respond to patients waiting for an ambulance. This is a national issue and in our region one that has more recently been given much focus by the entire healthcare system. We are starting to see some improvement but back in October 2017 thousands of hours were lost due A&E departments being unable to accept timely handover of patients from our crews. In addition, the demand for our services on the night in question was greater than had been forecast. Since then, there has been much improvement in how we forecast and during 2018 the ambulance and crew hours we have available much more closely match the level of demand. To summarise, it is clear that there was an error with the original classification of Mr Funnell and then a failure to upgrade his call. For this, I am sorry. Although this was human error, the recent NHS Pathways upgrade will significantly reduce the risk of such an error recurring. We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards. I do hope this information is helpful and if I can assist you further, please do not hesitate to contact me. Yours sincerely Chief Executive South East Coast Ambulance Service NHS Foundation Trust
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