Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0142, written 14 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2024 |
|---|---|
| Reference | 2024-0142 |
| Deceased | Joseph Miller |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths |
| 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: Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 6th June 2023 I commenced an investigation into the death of Joseph Michael Miller. The investigation concluded on the 2nd February 2023 and the conclusion was one of narrative: Died from the complications of a seizure contributed to by the use of cocaine. The medical cause of death was 1a) Hypoxic Brain Injury 1b) Cardiac Arrest on the background of a seizure and cocaine use 4 CIRCUMSTANCES OF THE DEATH On the 31st May 2023, Joseph Michael Miller was seen by a neighbour to be fitting in the garden of his home address. A call was made to the ambulance service that was initially categorised as category 1 but downgraded to category 3 when it was reported that he was no longer fitting. A further call was made when he had another seizure and became unconscious. Ambulance crews attended. The initial Rapid Response Team were there within eight minutes. He did not return to consciousness despite extensive efforts to resuscitate him. He was transferred to Tameside General Hospital where tests on the 3rd June confirmed severe hypoxic brain injury and he was declared dead on 5th June. 1 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. – 1. The inquest heard evidence that different ambulance services use different pathways that can impact how calls are categorised /downgraded. The consequence of this is that how the ambulance services across England deal with a call varies depending on where you live. As an example in this inquest, because of where Joseph lived, calls can go to EMAS or NWAS depending on which mobile telephone mast the call pings on. The initial call went to EMAS who on being told he was no longer fitting downgraded the call, in line with their pathway. The inquest was told that had the call been dealt with by NWAS they would not have downgraded the call to a category 3 in this situation because that was not how their pathway operated. 2. The consequence of these different pathways is that there is not a consistent approach to call categorisation across the country which can have a significant impact on the dispatch of potentially lifesaving attendance by the ambulance service. 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 by 9th May 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following 2 Interested Persons namely may find it useful or of interest. on behalf of the Family, who 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 Alison Mutch HM Senior Coroner 14.03.2024 3
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.
From Minister Helen Whately Minister of State for Care 39 Victoria Street London SW1H 0EU Alison Mutch, Senior Coroner for South Manchester Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 14 June 2024 Dear Ms Mutch, Thank you for your letter of 14 March 2024 to the Secretary of State for Health and Social Care Victoria Atkins, about the death of Joseph Michael Miller. I am replying as Minister with responsibility for urgent and emergency services. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Miller’s death and I offer my sincere condolences to his family. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention. Your report raised concerns about the two call triage systems in use by NHS ambulance trusts, and the potential for patients to be given a different ambulance categorisation depending on the system used. The Department’s officials have shared your report with the East Midlands Ambulance Service (EMAS), North West Ambulance Service (NWAS) and NHS England (NHSE) as the body responsibly for oversight of NHS ambulance services. Ambulance services are required to use an approved triage system to aid initial 999 call prioritisation – the two approved systems are the Advanced Medical Dispatch Priority System (AMPDS) and the NHS Pathways system. These systems are approved on the basis of being able to determine (as far as possible) differing levels of acuity, from immediately life- threatening emergencies to patients with an urgent care need. In considering the concerns raised about the potential for variation between categorisation, NHSE has advised the Department that it has in place a process to appropriately map the outcomes of 999 call triage systems against ambulance response time categories. NHSE has responsibility for the production, maintenance, review and revision of the dataset used in these systems, which is managed by the NHSE-chaired Emergency Call Prioritisation Advisory Group (ECPAG). ECPAG keeps the categorisation of calls under continual review, and ambulance services support this process through providing evidence and expertise to reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
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