Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0304, written 5 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2024 |
|---|---|
| Reference | 2024-0304 |
| Deceased | Bernard Compton |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) NHS England 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 25th October 2023 I commenced an investigation into the death of Bernard Compton. The investigation concluded on the 9th May 2024 and the conclusion was one of NARRATIVE: Died from a complication of a myocardial infarction when delays in identifying he had a myocardial infarction meant that the time for a successful percutaneous coronary intervention had passed. The medical cause of death was 1a) Left ventricular rupture with Hemopericardium; 1b) Acute myocardial infarction; 1c) Coronary artery disease II Tobacco smoking. 4 CIRCUMSTANCES OF THE DEATH On 13th October 2023 at about 20:23 Bernard Compton rang North West Ambulance Service reporting pain under his left arm, shortness of breath, shaking and sweating. He was categorised as a category 3. He was then assessed further and a taxi was sent to take him to hospital. He arrived at Tameside General Hospital at 21:37. He was streamed for an ECG based on his symptoms which included chest pain since 3pm that day. The ECG took place at 22:15. The machine indicated on the print out that he was having a myocardial infarction. It was misinterpreted by a doctor. It was to be repeated within 30 minutes. That did not happen. He was triaged at 23:24. A triage should have taken place within fifteen minutes but did not due to significant 1 demand on the department. He was categorised as urgent and should have seen a clinician within ten minutes. He was sent to sit in the main waiting area. At 02:06 the results of his bloods taken at 22:20 were reported on the hospital’s electronic system. They showed a significantly raised troponin. He was still in the waiting area. He had not seen a member of staff or been checked on. His results on the system were not reviewed until 05:12 due to demands on the staff. He had not been reviewed since he was triaged. He had left the department due to the wait and not being seen. Greater Manchester Police and the North West Ambulance Service were alerted. Greater Manchester Police returned him to Tameside General Hospital as delays with North West Ambulance meant there was a 45 minute wait for all category 2 cases, even though it was known he was probably having a heart attack. He was transferred to Wythenshawe (a tertiary cardiac centre) at 07:47. By that time the optimum 12 hour window for a successful intervention by percutaneous coronary intervention had passed. He remained at Wythenshawe. On 19th October 2023 he had a left ventricular rupture, as a consequence of the previous myocardial infarction and the damage it had caused to his heart and died. 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 the delays in the Emergency were due to demand and were not unusual. It was recognised that the delays presented a risk and steps had been taken to try to mitigate them but there was no evidence that particularly during the night hours any one person had oversight of patients or that there was a system to ensure effective management of patients. The situation Mr Compton experienced was a direct consequence of the lack of 2 oversight and system. 2. It was unclear what system was in place to effectively ensure urgent blood results were acted upon immediately. The inquest was told the lab would telephone through on some occasions. It was unclear what the protocol was and who had oversight of it. 3. The ECG told the clinician that there was a likely MI. It was entirely unclear why that was not acted on. The clinician did ask for a repeat within 30 minutes. That did not happen. There was no evidence of a system to ensure tests were repeated and directed and how that was monitored. 4. When Mr Compton made his first call to NWAS he was exhibiting symptoms consistent with an ongoing MI. However the questioning via the algorithm did not pick that up. NWAS were unable to clarify why that was the case. A call from someone actively having a MI was therefore categorised as a category 3 despite the time critical nature of the condition. 5. Demand on NWAS meant that even though they knew he had been diagnosed as being in the throes of a MI they could not get an ambulance to him in less than 45 minutes due to demand on their services. 6. The consequence of delay in assessing and treating Mr Compton was that an opportunity to treat him effectively was not available to clinicians. 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 31st July 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 Interested Persons namely Tameside General Hospital and North West 3 Ambulance Service, 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. 9 Alison Mutch HM Senior Coroner 05.06.2024 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.
Ms Alison Mutch
Senior Coroner
Manchester South Coroner’s Service
1 Mount Tabor Street
Stockport
SK1 3AG
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25 July 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Bernard Compton who
died on 19 October 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 June
2024 concerning the death of Bernard Compton on 19 October 2023. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Bernard’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Bernard’s care have
been listened to and reflected upon.
My response to you focuses on those concerns raised in your Report that come under
the remit of NHS England’s national policy or programme work. It would be more
appropriate for the North West Ambulance Service (NWAS) NHS Trust and Tameside
and Glossop Integrated Care NHS Foundation Trust to respond to some of the
concerns raised, and you may wish to revert to those Trusts for further information.
One of the concerns raised in your Report relates to the NWAS call algorithm and the
fact that this did not pick up that Bernard was exhibiting symptoms of an ongoing
myocardial infarction (MI), which resulted in the initial allocation of a Category 3
response when Bernard’s condition was time critical.
The NHS Pathways product team provides the NHS Pathways Clinical Decision
Support System (CDSS) urgent and emergency triage product. This product is used
in NHS 111 and over half of 999 ambulance services in England, including NWAS,
supporting the remote assessment of over 23 million calls a year. It is embedded within
host systems in those providers and interacts with other technology products to
support the assessment, sorting and onward management of calls received by those
services.
Calls to services using the NHS Pathways triage product are managed by specially
trained non-clinical Health Advisers. Their training is specific to the Pathways product,
and this enables them to use the information provided by callers to pass cases to
suitable services, based on the patient’s health needs at the time of the call. NHS
Pathways trained call handlers are supported by clinicians who may provide advice
and guidance, or to whom calls may be transferred, when required.
The NHS Pathways triage product is built to progress through a clinical hierarchy of
urgency. This means that life-threatening problems are assessed first, and less urgent
problems are assessed sequentially thereafter. The endpoint of an assessment is
reached when a clinically significant factor cannot be ruled out and so a “disposition”
is reached. Dispositions range from ‘Emergency Ambulance’ to ‘Self-Care’.
NHS Pathways is not a diagnostic system, and it assesses symptoms presented at
the time of the call and signposts to the next level of care by asking a series of
questions which progress through a clinical hierarchy of urgency. Accordingly, in
recognition of the seriousness of the conditions, questions seeking to identify
symptoms of a MI and heart attack are part of the questions asked at an early stage.
Within the Chest Pain Pathway, a Category 2 ambulance response is reached for
patients with active chest pain, or chest pain within 24 hours for those with a past
cardiac history, any risk factors such as an abdominal aortic aneurysm or Marfan’s
Syndrome, or those showing signs of sepsis. NHS Pathways recognises that cardiac
symptoms can have multiple presentations, and therefore the system also accounts
for pain in the upper back, between the shoulder blades, and in the arms, shoulders,
neck or jaw.
As part of their training, Health Advisers learn about probing for more information if
answers are unclear, or if callers do not know how to respond to a question, and NHS
Pathways supports this through the use of prompts alongside questions.
Clinical input can be sought at any point during the call by the Health Advisers. Health
Advisers can also ‘early exit’ a call if they believe it to be complex and pass it directly
to a Clinical Adviser. A complex call is defined as ‘any call which isn’t straightforward
and where the Health Adviser determines that they are working at or beyond the limits
of their knowledge’.
In this case, during the first call to NWAS, the Health Adviser identified that Bernard
was experiencing pain under his arm, shaking, sweating and breathlessness as the
main symptoms, and selected the Arm Pain or Swelling Pathway. Had further probing
around the location or nature of the pain occurred, it is possible that the Health Adviser
may have selected chest pain as a main symptom, allowing for further interrogation
into the symptoms and the possibility of a Category 2 ambulance response being
reached. Furthermore, if Bernard was unable to identify his main symptom, this call
could have been escalated as a complex call, enabling a Clinical Adviser to assess
the symptoms instead. However, Benard did not report chest pain when asked during
the call, as well as stating that he had not had a previous heart attack, which therefore
resulted in a Category 3 ambulance response within the Arm Pain or Swelling
Pathway. During the two subsequent calls from the Greater Manchester Police, a
Category 2 ambulance response was reached in response to the declared chest pain.
My regional colleagues in the North West have also engaged with NWAS on your
concerns and are advised that NWAS have identified that the call was safely and
appropriately triaged as Category 3 with the symptoms provided by Bernard on the
initial call. It was identified by NWAS at the time that the call was potentially suitable
to be supported by clinician callback and details were sent to the Greater Manchester
Clinical Assessment Service (GMCAS) for clinical assessment, as per agreed
governance processes and to assess if other local services could support Bernard’s
needs.
Following GMCAS contact with Bernard, they contacted NWAS to arrange transport
for Bernard to the local Emergency Department at Tameside General Hospital.
There was significant demand on both NWAS and Tameside and Glossop Integrated
Care NHS Foundation Trust in the Autumn of last year, with the Emergency
Department (ED) at Tameside under significant pressure and all areas of the ED full.
Health systems remain in recovery following the COVID-19 pandemic and pressures
arising from it and the societal response. NHS England’s recovery plans include a
focus on Urgent and Emergency Care, with one of the plan’s nine workstreams
including increasing ambulance capacity. Since October 2023, Tameside’s ED has
increased its capacity as part of a planned rebuild of the unit. My regional colleagues
have approached the Greater Manchester Integrated Care Board (ICB) for further
information regarding your concerns, as the local commissioner of the Trust. As
referenced above, you may also wish to approach the relevant Trusts or the ICB for
further information.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Bernard, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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