Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0192, written 10 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2024 |
|---|---|
| Reference | 2024-0192 |
| Deceased | Paul Dow |
| Coroner | Matthew Cox |
| Coroner area | Manchester North |
| Category | Suicide (from 2015) · Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. North West Ambulance Service ( NWAS) 2. Secretary of State for Health and Social Care CORONER I am Matthew Cox, Assistant Coroner for the Coroner area of Manchester North 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and ReQulations 28 and 29 of the Coroners (Investigations) Requlations 2013 3 INVESTIGATION and INQUEST On the 6th June 2023, I commenced an investigation into the death of Paul Dow, date of birth 26th August 1957 who died on the 3 April 2023 at the Royal Oldham Hospital The medical cause of his death was confirmed as 1 a) Combined drug toxicity 2) lschaemic heart disease, Type 2 diabetes mellitus, urinary tract infection. 4 CIRCUMSTANCES OF DEATH On 28th March 2023 Mr Dow was arrested and charged with criminal offences. On 29 March he was bailed subject to conditions not to go within 100 metres of his home address where he lived with his partner as a result of which he started staying at the Travelodge, Rochdale. Mr Dow was on his own in a room at the Travelodge when at 18.35 on 2 April 2023 he made an emergency call to the ambulance service. He made contact with a call handler employed by NWAS. He reported that he was a type 2 diabetic and said "I've taken a pile of tablets and I mean a pile" when asked whether this was an attempt to take his life he replied, "Well yeah, possibly." He was asked what he had taken and he said he had taken . When asked whether he had taken a lot, boxes of each he replied "yeah." He said he felt weird. Mr Dow was told there were delays of over an hour and a half in dispatching an ambulance. The call was coded as a category 3 response defined as 9 out 10 responses within 120 minutes. A clinician from the clinical hub attempted to call Mr Dow but received no response to calls at 19.09, 19.22 and 19.26. Mr Dow called the ambulance service again at 19.38 and spoke to the same call handler. He said "I've taken loads of tablets the ones I have for mv diabetes." He was asked aaain whether this was an attempt to take his life and said "I don't know, could be." This call was also coded as category 3. An ambulance arrived on scene at 20.27. Mr Dow stated to the paramedic that the overdose was intentional as he wanted to take his own life. Mr Dow was transported to hospital arriving at 21.43. Attempts to resuscitate him were unsuccessful and his death was confirmed on 3 April 2023. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion In the circumstances it is my there is a risk that future deaths will occur unless action is taken. statutory duty to report to you. The MATTERS OF CONCERN are as follows:- 1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3. 2. There was no involvement from a clinician at the time of either call. 3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated w ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 5 June 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 vou must explain whv 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 namely:- The family of Paul Dow North West Ambulance Service 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 from. 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 vour response by the Chief Coroner. Date 1O April 2024 Signed: ,:v .... I 9
2 responses 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 14 June 2024 Matthew Cox HM Coroner's Court Floors 2 & 3 Newgate House Newgate Rochdale, OL16 1AT Dear Mr Cox, Thank you for your letter of 10 April to the Secretary of State for Health and Social Care regarding the death of Paul Dow. I am replying as Minister with responsibility for urgent and emergency care. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Dow’s death and I offer my sincere condolences to his family and loved ones. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so NHS care can be improved. I am grateful to you for bringing these matters to my attention. Your report raised concerns about the service provided by the North West Ambulance Service NHS Trust response categorisation for patients who have taken an overdose and the clinical involvement in triaging such calls. the appropriate ambulance (NWAS), including My officials have made enquiries with NHS England (NHSE) who advise that national guidance is in place for Emergency Operation Centres (EOC) on the clinical oversight of patients calling with overdose and suicidal ideations. These principles have been reviewed and strengthened through several national recommendations since 2019. NHSE issued guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. The guidance sets out that, where an overdose is declared, further clinical intervention should take place so that an early assessment can be made of whether a higher priority response is more appropriate. This clinical intervention should take place within 30 minutes, or the case must automatically upgrade to a Category 2 if clinical intervention does not occur within 40 minutes. A3 You have also shared your report with NWAS who are best placed to respond on the specific action they are taking locally to address your concerns. I am informed that NWAS has reviewed how it uses the call handling triage tool (NHS Pathways) in calls that involve patients who have taken overdoses. Where NHS Pathways recognises a "risk of suicide” or "accidental poisoning or overdose" from the initial call triage, it will automatically prompt the call handler to continue with an advanced questionnaire module to determine if the patient has taken an overdose of a number of higher risk medications. Patients who have taken such medicines will automatically be upgraded to a Category 2 response at the point of the call. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY A4
Mr Matthew Cox His Majesty’s Assistant Coroner Greater Manchester North BY EMAIL ONLY 29 May 2024 Dear Mr Cox LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD nwas.nhs.uk Regulation 28 Report – Inquest Touching the Death of Mr Paul Dow I write further to your Prevention of Future Deaths Report which was issued to North West Ambulance Service (‘NWAS’) following the conclusion of the inquest touching the death of Mr Dow. I know that you will share my response with Mr Dow’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter, I will address those concerns as far as I am able to. 1. Despite a clear indication from Mr Dow that he had taken an overdose of a lot of medication with an indication that he did so to take his own life, the calls at 18:35 and 19:38 were both coded as category 3. Based on the information provided by him in response to the call handler’s questioning during both 999 calls made to NWAS, the outcome elicited by NHS Pathways for Mr Dow’s 999 calls was a category 3 response. The categorisation of emergency 999 calls, which are triaged through the NHS Pathways system, is standardised across England in all ambulance Trusts which use the Pathways system. Whilst ambulance Trusts can (and do) provide feedback to NHS Pathways with views/opinions on call categorisation, the decision as to categorisation is ultimately a decision for NHS Pathways. The triaging of calls involving an overdose of drugs (whether intentional or not) will result in a minimum categorisation, via Pathways, of a category 3 response. Individual factors relevant to the patient may indicate a more urgent threat to life and can result in an increased level of categorisation, if appropriate, based on the answers to the questions asked by Pathways. A5 In Mr Dow’s case, both calls made to NWAS have been audited and the outcome was that the eliciting of category 3 responses was appropriate. 2. There was no involvement of a clinician at the time of either call. At the time of his first call, Mr Dow was advised that an ambulance was being arranged, however in the meantime a clinician may call him back and that he should ensure his phone line was kept clear. At the time of these events, all category 3 and 4 calls presented in a ‘stack’ of calls in the Clinical Support Desk (‘CSD’) within the NWAS Emergency Operations Centre (‘EOC’), for review. The CSD is staffed by Senior clinicians who review all waiting category 3 and 4 calls in order to make a decision as to whether the call is appropriate for ambulance dispatch or whether further telephone triage is required. In Mr Dow’s case, this initial review by a CSD clinician determined that further telephone triage was required and therefore the call was passed to the Specialist Practitioner team within the EOC, which is staffed by Advanced Paramedics and Nurses. One of the Specialist Practitioners subsequently tried to contact Mr Dow on three occasions as per NWAS procedure. Unfortunately, as you are aware, those calls went unanswered. A clinical decision was then made for an ambulance to be dispatched in time order to Mr Dow. It was open to the Specialist Practitioner to upgrade the response, however, based on the information available, they made a clinical decision based on the information available not to do so. Accordingly, there was a clinician review of Mr Dow’s call at 18:35 on two occasions, firstly by the CSD clinician and secondly by the Specialist Practitioner who subsequently attempted to contact Mr Dow. Following the further 999 call at 19:38, Mr Dow was re-triaged through the Pathways system and again, a category 3 response was elicited. As the decision had already been made by the Specialist Practitioner to dispatch an ambulance the call was not passed for further clinician review. 3. Mr Dow was on his own in the hotel room. When a clinician called on three separate occasions there was no response. During her evidence, Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18:35 was not escalated. As set out above, when Mr Dow did not pick up the three calls made by the NWAS Specialist Practitioner, the decision was made by that clinician to dispatch an ambulance to him. This was, in and of itself, an escalation of the call, as it had initially been deemed appropriate for further telephone triage. It is common for return calls from the ambulance service to patients to go unanswered. In that scenario, it is not possible for this to result in an automatic upgrading of calls. Automatically upgrading the categorisation of all calls to patients that go unanswered would have a significant impact in the response the ambulance service is able to provide to patients who have already been triaged at a higher priority (for example category 1 and category 2 calls) and would place a significant burden on the Trust’s wider response times for all patient incidents, such that the achieving of target response times is likely to become unachievable. Accordingly, clinical decisions must be made, based on the information available, as to whether a call should be upgraded in the event a patient does not answer calls to them, as happened in Mr Dow’s case. In any event, where contact cannot be made with a patient as occurred in Mr Dow’s case, an ambulance dispatch will occur, however the categorisation of that ambulance has to be judged based on the information available. Changes in Practice I have also set out below work that has been done within NWAS, since Mr Dow’s death, which I hope will A6 provide you with confidence that the Trust’s procedures and processes have evolved, with a view to ensuring patient safety in similar cases. Review and Triaging of Calls Since Mr Dow’s death, there have been various operational changes within the Trusts EOCs with regards to how emergency calls are dealt with. Following these changes, calls involving an overdose will remain as a minimum category 3 disposition in line with NHS Pathways categorisation (unless a higher categorisation is reached based on the answers to the Pathways questions on signs and symptoms) but will now be sent for Clinical Navigation. The Clinical Navigation team is made up of clinicians working within NWAS EOCs, who will undertake a preliminary review of the information elicited during the 999 call. Based on this review the Clinical Navigator will make a decision as to whether the call (1) needs to be upgraded immediately, (2) should remain as a category 3 response and await ambulance dispatch accordingly or (3) requires further triaging. This is now the first line of clinician review in these types of calls and ordinarily takes place within 15 minutes of the 999 call being concluded. If the decision of the Clinical Navigation team is that a further telephone triage is required, then the call will be passed to the CSD where it will be reviewed by a Specialist Practitioner and a call to the patient will be made to undertake the further triage and the most outcome based on that triage will then be arranged. In cases of overdose / poisoning, if the further triage by the Specialist Practitioner does not take place within 30 minutes, for example during periods of high demand on NWAS services, the call will pass to the Clinical Coordination Desk (‘CCD’) for consideration and the Trust’s welfare module will be enacted. This can result in (1) an upgrade of the call categorisation, if deemed clinically necessary (2) dispatch of an ambulance in line with the calls current categorisation (3) awaiting further triage by the CSD or (4) immediate triage by a patient safety clinician with the CCD. At all stages in the process set out above, it is open to the clinicians involved to upgrade a call if they deem it clinically necessary. Training In line with the changes made with regards to the review and triaging of calls as summarised above, the Trust’s clinicians working in the Clinical Navigation, CSD and CCD teams have undergone extended training on dealing with and reviewing cases of overdose / poisoning, including making use of resources such as TOXBASE® (TOXBASE® is the clinical toxicology database of the UK National Poisons Information Service) to help support clinical decision making when excess medications have been ingested. This additional and extensive training enables the Trust’s clinicians to make appropriate clinical judgments and to ensure that affected patients receive the most appropriate treatment in a timely manner. I am sorry that you felt it necessary that there was cause to issue a Prevention of Future Deaths Report and I hope that, by this letter, I have addressed your concerns. Should you require any further clarification or information, please do not hesitate to contact me or the Trust’s Head of Resolution, . Yours sincerely, Chief Executive (cid:34)(cid:24)
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