Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0686, written 24 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2024 |
|---|---|
| Reference | 2024-0686 |
| Deceased | Alice Clark |
| Coroner | Roger Hatch |
| Coroner area | North West Kent |
| 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.
North West Kent Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: 03000 410502 Email: kentandmedwaycoroners@kent.gov.uk Date: 24 October 2024 Case: 34174461 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of the South East Coast Ambulance Service 1. CORONER I am Roger Hatch, Senior Coroner for the coroner area of North West Kent 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 19 January 2022 I commenced an investigation into the death of Alice Olivia CLARK. The investigation concluded at the end of the inquest . The conclusion of the inquest was Narrative: The death of Alice Olivia Clark was due to a road traffic accident but that there was a failure by the South East Coast Ambulance Service in their investigation of complaints they had received from other members of their staff over the driving of had been acted upon could have changed the outcome. where if it 1a Lower Limb & Pelvic Fractures with Retroperitoneal Haemorrhage 1b Vehicular Crash 1c 1d II 4. CIRCUMSTANCES OF THE DEATH to an emergency call on blue lights, when At 20.16 hours on Wednesday 5th January 2022, a road traffic collision involving a SECAMB ambulance was reported to Kent Police on the A21, Coastbound at Tonbridge. From the information known at the time of writing, it would appear that a marked SECAMB ambulance (Vehicle 1) was being driven by for reasons currently unknown, the vehicle has taken the slip road towards the layby (where the collision occurred) instead of the next exit, which goes off the A21 towards the Morley's Road roundabout / A225. Upon entering the layby, the ambulance has collided with the offside kerb, then rear nearside of a stationary and attended Scania Dropside lorry which was parked to the offside of the layby, the force of which has caused the ambulance to cross the layby to the nearside, where it has then collided with the rear of a stationary and attended Volvo Tanker cement lorry. The impact caused the ambulance to become embedded into the rear of the tanker, trapping both the driver and front seat passenger (Miss Alice CLARK) within the vehicle. A third occupant, to exit the ambulance with assistance however suffered severe concussion and possible bleed on her skull. Miss CLARK was extricated from the front of the ambulance by KFRS and HEMS attended. Following assessment, HEMS Doctor and declared life extinct at 21.42 hours. The driver, front of the ambulance and flown to Kings College Hospital with life threatening injuries. Officers from the Serious Collision Investigation Unit were deployed to scene and arrived to commence an investigation at 21.35 hours. stated there were no signs of life , was also extricated from the was seated in the rear of the ambulance. was able 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Complaints had been received by other paramedic passengers as to the unsafe driving standards of occur in the future and put lives at risk and these were not dealt with appropriately. I am concerned that this could (2) No formal complaint procedure in place. I am concerned by the evidence that a paramedic raises a complaint with their supervisor and there are no written notes/statement taken and the paramedic is not updated regarding the investigation/outcome. I am concerned that without a set complaint procedure in place with statement taking, interviews and time limits lives could be at risk. (3) Driving standards are assessed by 'drive outs' with managers - should this be carried out by independent assessors and completed within a set time i.e. every 6 months or equally cctv reviewed on a regular basis of the driving standards. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Chief Executive of the South East Coast Ambulance Service 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 12th December 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 Mr and Mrs Clark (parents of Alice Clark). 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. 24 October 2024 Signature Roger Hatch Senior Coroner for North West Kent
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.
Mr R Hatch H M Senior Coroner for North East Kent 17 January 2025 Dear Sir Alice Clark deceased I write in response to the Regulation 28 Prevention of Future Deaths report received on the 13th December 2024 following the inquest into Alice’s sad death. We have taken robust action to learn from and address the concerns you highlight regarding driving standards complaints, responses and supervision. I would like to address each of your concerns in turn: 1. Complaints had been received by other paramedic passengers as to the unsafe driving standards of ER and these were not dealt with appropriately. I am concerned that this could occur in the future and put lives at risk. We strongly support the need to ensure colleagues are encouraged to raise any concerns they have, and that they feel comfortable in doing so. Our new driving policy which was published in August 2023 contains three new Appendices on Speaking Up and how to raise any concerns about colleagues’ driving (please see below). A stand-alone Speak Up Driving Standards campaign is due to be launched across the Trust in January 2025 (awaiting a final approval of a minor amendment to the policy). A QR code has been set up which links directly to a Microsoft form (easily accessible) which in turn will be sent direct to Driving Standards who will investigate all submissions. These are investigated promptly in liaison with the relevant departments such as Driving Standards/Driver Training/HR/Professional Standards. In March 2023 a new weekly Driving Standards Review Panel was formed. This comprises supervisors from Operations, Risk, Security, Patient Safety, Driving Standards and Professional Standards. Any driving concern that has been raised and progressed through to Driving Standards is discussed, an outcome which can range from words of advice, through to face-to-face meeting and follow up Driver Training, to formal HR procedures; a concern could also be referred to the Police. Any concern can be raised confidentially and will be treated appropriately by Driving Standards, who will maintain a spreadsheet from the Speak Up campaign which will allow us to tie up more than one report and treat them as a bigger picture, using the information supplied on the MS form. Staff will be able to report anonymously but will need to provide some basic information to allow Driving Standards to investigate the complaint – such as date, time, location etc to allow cctv/telematics to be viewed. This new process will form part of scene management training for all Operational Supervisors commencing in February 2025, run by Driving Standards to include how to handle repeated concerns about an individual’s driving and the Driving Standards Review Panel will actively monitor for repeated concerns. Every student who attends the Driver Training Unit for their initial emergency response (CERAD) course is taught how to report driving standards concerns and to recognise poor driving with their peers. This is covered within a Human Factors training session. A human factors/confrontational session for all emergency driving staff is also now included in their yearly Key Skills training days. 2. No formal complaint procedure in place. I am concerned by the evidence that a paramedic raises a complaint with their supervisor and there are no written notes/statement taken and the paramedic is not updated regarding the investigation/outcome. I am concerned that without a set complaint procedure in place with statement taking, interviews and time limits lives could be at risk. As described above, the new Driving Standards Policy includes a documented mechanism for concerns to be raised. Driving Standards will speak to the complainant direct with appropriate support from line manager/union colleagues if they wish. Notes are now taken of meetings in response to such concerns, which form part of an investigation and presentation to the Driving Standards Review Panel. This will support other evidence such as CCTV and telematics. The complainant is now kept up to date with the investigation and will be given an outcome. A flow chart has been created by Driving Standards for Managers to follow to ensure any complaints are forwarded to Driving Standards for investigation. This flow chart will form part of the upcoming scene management training for all Operational Supervisors starting in February 2025. Formal timescales for response are not set as these depend on the nature of the response required. However, Driving Standards will pick up an investigation as soon as it is raised and as there is a weekly meeting of the Panel the response will be timely. As soon as evidence is gained, it will be taken to the next weekly review panel and an outcome/advice forwarded that same afternoon to the relevant people. If a concern were to come via PALs for instance, Driving Standards are copied into the initial email and would route this to the Driving Standards Review Panel, hence it would receive the same response level. 3. Driving standards are assessed by 'drive outs' with managers - should this be carried out by independent assessors and completed within a set time i.e. every 6 months or equally CCTV reviewed on a regular basis of the driving standards. Official driving assessments are carried out by a fully qualified driving instructor inline with Section 19 criteria and follow the standard objectives from qualifications taught by the awarding body (Futurequals). The assessments are bespoke training to the individual’s needs and are carried out by the Driver Training team only. Any reviews from the Driving Standards Review Panel are now carried out by dedicated, qualified Driving Instructor from the SECAmb Driving Team who works directly with the Review Panel to ensure any referrals are completed in a standardised and timely manner. A written report is then forwarded to the local supervisor as well as to Driving Standards. A ‘drive out’ with a local supervisor may be part of an outcome in an informal manner as a wider supporting mechanism. In addition, Section 19 of the Road Traffic Act 2008 is well embedded into the Trust and has been for more than three years. This requires every response driver to be reassessed within every 5 years. In addition, there is yearly theory learning via our Key Skills course, which is mandatory training for all drivers. If any driver has been out of the Trust for any reason such as maternity or long-term sickness, they are given a driving assessment with a fully qualified Driving Instructor from the Driving Team on their return to work and they are asked to complete the online modular training before returning to full driving duties. Following an RTC or driving behaviour concern, line managers and/or driving standards will request CCTV. This is then viewed and if appropriate (for learning and education) is presented at the next Driving Standards Review Panel. An outcome will often be for the driver to have a face-to-face meeting with Driving Standards and as part of the learning, the CCTV is viewed together and discussed. This meeting can include the TU representative and line manager as applicable. The driver is regularly asked if they are happy that driving standards use the CCTV clip for Trustwide learning and for driver training (in a non-identifiable way) to encourage an open culture of improvement. I hope this response clearly sets out our commitment to learning from Alice’s tragic death and to ensuring that our processes are thorough and robust. If I can be of any further assistance, please do not hesitate to contact me. Yours sincerely Chief Executive
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