Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0307, written 6 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 | 6 Jun 2024 |
|---|---|
| Reference | 2024-0307 |
| Deceased | Robert Fray |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | 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.
1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) (2) CORONER , Chief Executive, West Midlands Ambulance Service. , Chair, NHS England. I am James Bennett Area Coroner for Birmingham and Solihull. 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 24/04/23 I commenced an investigation into the death of Robert John Fray. The investigation concluded at the end of the inquest on 23/05/24. CIRCUMSTANCES OF THE DEATH On 04/04/22 at a dialysis session Mr Fray was advised to attend hospital due to being symptomatic of sepsis. Arrival of an ambulance was delayed due to exceptional but not unprecedented demand. Sequence of 999 telephone calls: No.1 - was made by a clinician from the Dialysis Treatment Centre at 18:03hrs and triaged by the call assessor via the Healthcare Professional Pathway as a category 3 response. No.2 - was made by a clinician from the Dialysis Treatment Centre at 19:32hrs and upgraded by the call assessor to a category 2 response. No.3 - was made by a clinician from the Dialysis Treatment Center at 22:17hrs. It was explained the centre was closing and Mr Fray was going home. He had a NEWS 1. The call assessor maintained the category 2 response upon it being reported there was no change in Mr Fray’s presentation. 4 No.4 – was made by a neighbour at 23:05hrs with Mr Fray presenting with worsening symptoms. As the address was different, despite Mr Fray’s name being the same, the call assessor did not pick up it was a duplicate and this was triaged as a new category 2 response. In response to 999 calls no.1-3 an ambulance was dispatched at 23:32hrs and arrived at the Dialysis Treatment Centre at 23:46hrs to find it closed. The ambulance crew telephoned Mr Fray who confirmed he was at home. The ambulance arrived at his home address at 00:00hrs. He had a NEWS 10. He was admitted to the emergency department at Queen Elizabeth Hospital Birmingham around 01:16hrs on 05/04. Contrary to expectations, the ambulance crew did not pre-alert the hospital to 'red flag sepsis’ and did not handover Mr Fray's high NEWS or suspected sepsis verbally upon arrival. The navigation nurse streamed him to 'ambulatory majors'. The nurse in charge of 'ambulatory majors' recorded clinical observations on the hospital handover sheet that should have triggered a sepsis alert and prompt treatment, which at that stage would have prevented his death. Mr Fray was directed to the waiting area where he remained from 01:16hrs until he was found unconscious in a chair at 16:35hrs. For reasons that remain unknown he did not respond when verbally called for triage at 02:53hrs, and at 04:39hrs he was incorrectly recorded as having left without being treated. The emergency department was under exceptional but not unprecedented pressure during a period of COVID restrictions and there had been no nurse available to monitor the waiting area. Upon assessment he was critically unwell with sepsis, which was the primary cause of his collapse, and he had suffered a stroke. He was treated with fluids and antibiotics but was not a candidate for thrombolysis. He developed worsening multi-organ failure and died on 09/04/22 from: 1a Multi-organ failure. 1b Right MCA stroke and dialysis acquired acute sepsis. 1c II End stage renal disease secondary to uncontrolled hypertension on haemodialysis. The conclusion as to the death was: “Natural causes contributed to by a delay in diagnosis and treatment of sepsis. His death was contributed to by neglect.” 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. 5 1. A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls. 2. Linked, the automated ‘duplicate checker’ is based on checking location within a 250-meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters. 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. 6 West Midlands Ambulance Service are responsible for implementing NHS Pathways locally. NHS England are responsible for NHS Pathways. YOUR RESPONSE 7 8 You are under a duty to respond to this report within 56 days of the date of this report, namely by 1 August 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 the Chief Coroner and to the following Interested Persons: 1. Mr Fray’s family. 2. University Hospital Birmingham NHS Trust. 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 6 June 2024 James Bennett Area Coroner, Birmingham and Solihull
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.
Mr James Bennett
HM Area Coroner
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
coroner@birmingham.gov.uk
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
england.coronersr28@nhs.net
24/07/2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Robert John Fray who died
on 9 April 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6 June
2024 concerning the death of Robert John Fray on 9 April 2022 and sent to the Chair
of NHS England. I am responding on behalf of the organisation in my capacity as
National Medical Director but would like to assure you that the Chair has also been
sighted on this response and has reviewed your Report. In advance of responding to
the specific concerns raised in your Report, I would like to express my deep
condolences to Robert’s family and loved ones. NHS England are keen to assure the
family and the Coroner that the concerns raised about Robert’s care have been
listened to and reflected upon.
Your first concern in your Report focused on repeat 999 calls and raised that a volume
of 999 calls about the same person over a longitudinal period does not trigger or
prompt NHS Pathways to require the call assessor to consider whether a more urgent
response is needed.
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 ambulance callouts to self-care.
Triage is a fluid process. During a call, or afterwards, the symptoms can change (either
deteriorate or improve). Prior to closing a call, call handlers offer specific closing
instructions. These include providing information on what to do whilst waiting for the
ambulance and what to do if symptoms change, or if there are any other concerns
once a call has ended. This means that if symptoms change, for example becoming
immediately life-threatening, the person is encouraged to call back. This call back will
prompt reassessment that, in the case of immediately life-threatening symptoms,
upgrades the ambulance disposition accordingly.
It is critical that Urgent and Emergency Care triage products, such as NHS Pathways,
ensure that patients’ symptoms are assessed in a timely manner. This means that the
appropriate level of care or advice can be provided to the caller rapidly and safely. An
NHS Pathways triage assessment assesses symptoms at the time of the call. If all
patients who had a previous 999 contact or a previous encounter with a healthcare
provider were treated differently when a call reaches the 999 system, this could delay or
prevent an NHS Pathways assessment occurring. This could in turn delay ambulance
dispatch or life-saving advice.
In this case, a Category 2 ambulance disposition was reached during the second call at
19:32 hours. A Category 2 ambulance disposition is an emergency response that
requires a response within 18 minutes. The case-mix includes time-critical, serious
medical emergencies such as a heart attack or stroke in patients who are currently
breathing and conscious. A Category 1 response is reached when there is an immediate
threat to life, for example, where patients are not breathing (cardiac arrest).
As an operational measure developed in partnership with providers, where there is a call
open for a patient (identified via the demographic information collected at the outset of a
call), the caller is asked “Is the call about a new or worsening symptom?”. If the answer
is “yes” to either, reassessment will occur. This also supports services to manage call-
backs received where callers seek information about other matters, such as the expected
arrival time of an ambulance, and it enables cases to be upgraded where the patient has
deteriorated in the intervening period.
Your Report also raised the concern that the automated ‘duplicate checker’ for 999 calls
is based on checking location within a 250-metre radius, rather than the patient’s name.
In this case, Mr Fray had moved more than 250 metres between the third and fourth 999
calls, and so the fourth call was not picked up as a duplicate or call-back.
NHS England do not set national policy on how ambulance services should manage
duplicate callers. Ambulance services adopt good practice and implement their own
local procedures to manage this issue. The duplicate checker referred to by the
Coroner is good practice across the sector but is not nationally mandated policy.
In terms of local procedures, the Computer Aided Dispatch (CAD) systems geofence
(i.e. set a boundary) at a 250-metre radius, and may additionally differentiate
duplicates based upon one or more of the following, depending on how the system is
configured:
- Telephone number
- Location/address
- Key phrase (e.g. difficulty breathing)
- NHS number
- Age
- Sex of the patient
Outside of the geofence, the ‘what3words’ function may also support this identification
process. This is a geocode system designed to identify every 3-metre square of the
Earth, and it is a helpful way to communicate exact locations.
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 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,
Professor Sir Stephen Powis
National Medical Director
Your Ref: Our Ref: Mr Bennett Area Coroner for Birmingham and Solihull 50 Newton Street Birmingham B4 6NE 17 July 2024 Dear Mr Bennett Re: Robert John Fray Thank you for your email dated 6 June 2024 attaching your Regulation 28 Report. Firstly, I am sorry that you have had to raise concerns with West Midlands Ambulance Service University NHS Foundation Trust (WMAS) following the inquest of Mr Fray. Can I please take this opportunirty to pass on my sincere condolences to the family of Mr Fray. I have addressed the specific concerns raised in the regulation 28 report below. Following a full review of the case I also wish to take the opportuntiy to make some additional observations and additional clarity around the sequence of events. Please see our response to your concerns. Concern 1 A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls. Response The Trust answers, triages and processes 999 calls in-line with established call taking protocols that detail the required actions for managing duplicate or repeat calls. Most duplicate calls received are not because a patient’s condition has changed, they are because a caller is seeking an estimated arrival time. These calls are not routinely retriaged as it has been confirmed that there is no change in the patients presenting condition which means that the response category will not differ from that originally established. All duplicate calls from patients or callers, where it is confirmed the condition of the patient has changed or worsened will receive a full NHS Pathways triage. If the Page 1 of 4 triage has resulted in a higher category of call, then the new category becomes the required response to the patient. As described in the circumstances relating to the Regulation 28 Report to Prevent Future Deaths, during the fifth 999 call that originated from a neighbour, Mr Fray received a further triage of his symptoms requiring a category 2 response. A higher response category would not have been achieved, due to Mr Fray being reported as conscious and breathing regularly. This call would therefore not have changed the priority of the existing response. The Trust does acknowledge that the final call from the neighbour was not identified as a duplicate call for Mr Fray and was therefore not linked to the original calls. This resulted in an ambulance responding to the location of the initial call, creating a further delay to Mr Fray. Contact was made with Mr Fray and the ambulance subsequently responded to his home address. I wish to convey my apologies to Mr Fray’s family, as this further delayed the response by 14 minutes. The Trust acknowledges the concern raised in Regulation 28 Report to Prevent Future Deaths, relating to the management of repeat calls. The Trust details the actions to identify duplicate, or repeat calls, in response to concern 2 below. In response to your first recommendation, the Trust will implement a change in call taking protocol that requires a clinical review of a patient’s condition where three or more repeat calls are identified. This will support an immediate review of the patient’s call history and presenting symptoms. Concern 2 Linked, the automated ‘duplicate checker’ is based on checking location within a 250- meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters. Response The Trust has two methods for identifying potential duplicate or repeat 999 calls for the same incident. The first is the ‘duplicate checker’, referred to above which identifies cases received in the previous 3 hours, within a 250-meter radius and up to 30 minutes after the case is closed. The intention of the duplicate checker is to identify multiple calls that may relate to the same incident, for example, multiple calls for an incident on a motorway. The second method is the ‘Call Location History Checker’ which will recognise and record when three or more 999 calls have been received to an exact location, over a 24-hour period. The Trust is sorry that in the case of Mr Fray neither method described correctly identified the final call to his home address as a duplicate call. The Trust therefore agrees with the recommendation within the Regulation 28 Report to Prevent Future Deaths to implement an alternative method for detection based upon the patient's personal demographics. A formal development request and specification has been submitted to our Computer Aided Dispatch (CAD) system provider, Cleric Computer Services. The development details identification of repeat calls based upon personal demographics; to include, the patient’s name, date of birth, NHS number, and the patient’s or caller’s telephone number. This is therefore not limited to the current location and radius settings within the existing methods described. Page 2 of 4 Cleric Computer Services have acknowledged the development request and confirmed feasibility to deliver the requirements. The Trust does not have a date for implementation due to the technical work required; however, Cleric have acknowledged the associated Regulation 28 Report to Prevent Future Deaths and the necessity to implement promptly. Additional Observations In total there were four calls received from the Kidney Treatment Centre (not three as suggested in the PFD) as detailed below, all of which were calls made by clinical members of staff from the centre. Please note that the time of calls listed below are electronic time stamps from within the Trusts computer systems and accurately reflect when the calls were answered by the ambulance service. The first call was received at 18:03 hours and, based upon the information provided by the clinician the call was correctly coded as a category 3 incident. At the time of this call West Midlands Ambulance Service was under significant pressure with 629 unallocated emergency calls awaiting a response, 209 of which were in Birmingham. The second call was received at 19:32 hours. The clinician making the call confirmed that he was calling to chase an estimated time of arrival (ETA) for the ambulance and did state that there had been no deterioration in the patient’s condition. However, the call assessor prompted the caller, asking if he felt that a high priority was required and also asked directly if he thought that the patient may be suffering from sepsis. To this end the call was correctly categorised as a Category 2 incident. There were still no ambulances available to respond as there were 529 emergency incidents outstanding, 216 of these were category 2 incidents, 97 of which were in Birmingham. A third call was received at 21:18 hours where the clinician making the call confirmed that the patient’s condition had not changed and that he was requesting an estimated arrival time of the ambulance. The call assessor correctly informed that the Trust was extremely busy at the moment and that she was unable to provide a timeframe and advised that if Mr Frays condition did deteriorate then please call back. As the patient’s condition had not changed the category 2 response remained. A fourth and final call from the treatment centre was made at 22:17 hours where it was confirmed that Mr Frays condition had not worsened but they were calling to see when an ambulance may arrive as the centre would be closing soon. The call taker was unable to provide a specific time frame for a response but did confirm that Mr Fray was a high priority call and that as soon as an ambulance was available to respond then it would. During this call there was no mention that Mr Fray would be going home. A fifth call in relation to Mr Fray was received at 23:05 hours. This call was made by one of Mr Frays neighbours who confirmed he had just returned from dialysis and that he had been informed that he had an infection. Mr Fray had just got back and not made it into the house yet as he was being sick and shaking. The call taker correctly asked to speak to Mr Fray who tried to speak to the call taker but found this difficult, so the phone was handed back to the neighbour. The neighbour confirmed that the treatment centre did want to send him to the hospital, but Mr Fray did not want to go. The call was correctly categorised as category 2 and was recorded as a new case because it was a new location and there was no indication that a call already existed in the system for Mr Fray, and there was no mention that Mr Fray was already waiting for an ambulance response during the call. When listening to all four calls that originated from the treatment centre as listed above there was never a mention of Mr Fray leaving the centre and returning to his home address. This is why the ambulance crew that did eventually become available to respond to Mr Fray firstly went to the Kidney Treatment Centre as this was still a live incident and had been waiting the longest. When the crew arrived at the centre to find it was closed, Page 3 of 4 they contacted the EOC who in turn contacted Mr Fray directly where it was identified that he was now at his home address. The location for the incident that the crew were already tasked to was amended and the crew arrived with Mr Fray at midnight and provided treatment and onward conveyance to the Queen Elizabeth hospital, they arrived at 00:59 hours. On this day in question the Trust was under a great deal of pressure, not specifically because of increase demand but due to the significant and consistent hospital handover delays which meant that over 1,756 operational hours were lost due to extensive hospital handover delays. To put this into perspective it equates to losing 25% of the staff on duty for the day. The Target for hospital handovers is 15 minutes, the 1756 lost hours is in excess of the 15-minute handover target. The Trust prides itself on having the very best response times and for the clinical excellence offered to patients and service users however the lost hours seen on this day, due to hospital handover delays, significantly impacted on the Trusts ability to respond in a timely manner. I wish to convey my personal condolences and sincere apology to Mr Fray’s family for the time taken to respond an ambulance to Mr Fray following the initial call from the dialysis centre and for the further delay whilst responding from the kidney treatment centre to Mr Fray’s home address. Please do not hesitate to contact the Trust if you require any further information. Your sincerely IEUC & Performance Director Cc: Page 4 of 4
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