Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0064, written 3 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2025 |
|---|---|
| Reference | 2025-0064 |
| Deceased | Wyllow-Raine Swinburn |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | Child Death (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.
Wyllow-Raine Lawson Swinburn REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: of SOUTH CENTRAL AMBULANCE SERVICE , CHIEF EXECUTIVE 1 CORONER I am Mr Darren Salter, Senior coroner, for the coroner area of Oxfordshire 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 2nd December 2024 at Oxfordshire Coroner’s Court I conducted the inquest into the sad death of Wyllow-Raine Swinburn, aged 3 days, at the John Radcliffe Hospital Oxford on 30th September 2022. Her cause of death was found to be congenital hyperinsulinism and hypoglycaemia leading to a cardiac arrest. I returned a Narrative Conclusion as follows; Wyllow-Raine Swinburn was born on 27th September 2022 at the John Radcliffe Hospital, Oxford. She was discharged on the evening of 29th September 2022 with no significant concerns and went home with her mother to fed that evening and in the early hours. She stirred again at approximately 04:00 hours and her mother attempted to feed her but at approximately 04:36 hours her movements suddenly stopped, and she became unresponsive. An ambulance was called at 04:38 hours, but the call did not connect to an ambulance service until 04:45 hours when instruction on CPR was given and followed. The first paramedic arrived at approximately 05:09 hours and took over CPR, assisted by other ambulance personnel, who arrived a few minutes later. , Didcot. She There was helpful evidence in the form of statements from SCAS staff including , who also gave oral evidence. South Central Ambulance Service (SCAS) were legally represented and provided with a copy of the inquest file. 4 CIRCUMSTANCES OF THE DEATH The brief circumstances of Wyllow-Raine’s sad death are set out in the Narrative Conclusion above. It will be seen there was a delay of 7 minutes in the 999 call being connected to an ambulance service, initially East Midlands and then SCAS. The response time for the first paramedic to attend was 31 minutes. She died in hospital on 30th September 2022. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The two concerns relate to, firstly, the length of time for the 999 call to be connected to a ECT (Emergency Call Taker and, secondly, the length of time for an ambulance/paramedic to attend. I fully appreciate there have been very significant demands on ambulance services including on SCAS in the past few years. I also understand, from the written and oral evidence of , that multiple actions have been undertaken to improve ECT staffing and inconsistency. My primary concern is in relation to this first issue. I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times. It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity. Given the risk associated with delayed response times, particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter. I would be interested to learn if actions identified as part of SCAS’s own internal review have been fully implemented and are subject to auditing to ensure compliance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you South Central 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 1st April 2025. 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 The Family of Wyllow-Raine Swinburn -SCAS Legal Service Manager I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 2 You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 [DATE] [SIGNED BY CORONER] 3rd February 2024 3
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 D.M. Salter
HM Senior Coroner
24 April 2025
Dear Mr Salter,
Our Ref: MM
Your Ref:
Inquest into the death of Wyllow-Raine Swinburn
Thank you for raising the questions with me and allowing an opportunity to respond. I apologise for the delay
in answer as I did not receive the written letter. I provide the answer to your questions below:
1. I understand a BT Operator will listen to the caller/background noise to identify if the call is critical. I
am not clear if this happened in this case?
The BT Operator remained online with the caller listening and providing comfort messages until the
Ambulance answered the call. Paragraph 14 of my statement refers.
2. I am not clear if, routinely, an operator continues to listen for the duration (before connection to the
ambulance service) and while the caller is on hold or simply has the ability to listen in periodically
while also taking other calls.
The BT operator will listen until the Ambulance Service answer unless the temporary procedure contingency
is used. Paragraphs 12 and 13 of my statement refer.
3. A further concern was raised by family that the automated message that repeats itself continuously
could potentially interfere or drown out what is being said or happening at the caller's end if indeed
the automated message is one that is also heard by the BT operator.
The BT Operator will also hear the queue announcement played by the Ambulance Trust. The Pecs Code of
Practice provides guidance for Emergency Services with regards the queue announcement. If BT has any
British Telecommunications PLC
Registered Office:
One Braham Street, London E1 8EE
Registered in England No 1800000
Relationship Manager
Emergency Authority and
Government
concern regarding the volume or timing of a particular queue announcement impacting on call handling, this
is fed into the particular Emergency Service. Paragraph 15 of my statement refers.
4. Finally, it is understood the Critical Call Process was not used on the call in question. A concern that I
have is whether BT has an effective process in place to identify a critical call and prioritise it
accordingly
BT has a Critical Call Process to identify a critical call where the BT Operator hears speech or sound that
indicate an imminent or immediate risk to life. BT has agreed with Ambulance Trusts nationally which
category of calls they consider critical and would trigger the Critical Call Process if the BT Operator were to
hear speech or sound to suggest those scenarios. Paragraphs 3, 4 and 10 of my statement refer. Distress
alone is not an agreed trigger for the Critical Control Process.
Critical calls are prioritised by connection to the Trust secondary line which is at the head of their queue.
Paragraph 7 of my statement refers. If the Trust does not quickly answer, the BT Operator will connect to
another Trust secondary line. BT also hold a Critical Contact number for each Trust as documented in section
4.1 of the PECS included in Exhibit KS1.
I hope that this information provides the required clarification on the points raised.
Yours sincerely,
999 Emergency Authority and Government Relationship Manager
British Telecommunications PLC
Registered Office:
One Braham Street, London E1 8EE
Registered in England No 1800000
Relationship Manager
Emergency Authority and
Government
British Telecommunications PLC
Registered Office:
One Braham Street, London E1 8EE
Registered in England No 1800000
Karen Smith
Relationship Manager
Emergency Authority and
Government
Tel: 0331 625 1222
Mob: +44 7885 186370
Email: karen.smith@bt.com
South Central Ambulance Service NHS Trust Unit 7 & 8 Talisman Business Park Talisman Road Bicester, Oxon OX26 6HR Tel: 01869 365000 ) 26th March 2025 PRIVATE AND CONFIDENTIAL Mr Darren Salter HM Senior Coroner for Oxfordshire Via email only ( Dear Mr Salter, I am writing to you in response to the concerns that you highlighted following the inquest hearing into the very sad death of Wyllow-Raine Lawson Swinburn that concluded on 2nd December 2024. Thank you for allowing us the time to review and respond to your concerns. To confirm, your Regulation 28 report detailed your concerns regarding the time that it took for the 999 call made on 30th September 2022 to be answered and the time that it took for an ambulance to arrive at Wyllow-Raine’s home address. You confirmed that your primary concern related to the time that it took for the 999 call to be answered. However, I will cover both concerns within this letter to offer you reassurance that the Trust is doing all that it can to provide a safe and responsive service for the communities that we serve. Thank you for recognising the significant improvements that the Trust had already made by the time the case came to be heard within your Regulation 28 report. The safety of our patients is of paramount importance to the Trust, and we will always actively seek to make improvements where we can. In relation to call answer time, you are already familiar with the critical call process available where a BT operative becomes aware of, or is informed of, a time critical situation from the evidence provided to you for the inquest by both SCAS and BT. I have therefore not covered this within my letter but can confirm that this process remains in place. Since December 2023, the Trust has introduced a Fit for the Future programme (FFF). Under this programme the Trust has initiated an improved way of working in various areas of our workforce. The improvements are designed to ensure that we provide our patients with the care that they need safely and effectively in a timely way. Improvements made within our Clinical Coordination Centre (CCC) Within the CCC we have undertaken the following work in addition to the work that you have already been informed of via evidence for the hearing: • We have commenced a remodelling exercise to identify the number of Emergency Call Takers (ECTs) required to deliver a reliable service for the operational demand that we are working to. The increase in call answering ability has resulted in a significant decrease in our average call answer time. As explained to you at the inquest hearing, comparing September 2022 to September 2024, the average call answer time fell from 50 seconds to 10 seconds. In January 2025, this had reduced further to an average call answer time of 8 seconds. • The Association of Ambulance Chief Executives (AACE) is supporting us whilst we are undertaking our improvement plan. The plan is designed to improve call answer times, redesign our rotas, increase the spread of shifts to minimise shift changeover shortages, increase clinical support in the CCC to support ECTs and prioritise early clinical intervention in more complex cases. • We have commissioned an external organisation, ORH, to review our CCC staffing capacity modelling to ensure we have the correct skill set and operational model which is fit for the future. • We are continuing to work in partnership with the Isle of Wight NHS Trust to increase ECT numbers and availability. • We are refreshing our dispatch models to ensure multiple vehicles are not dispatched to an incident to maintain resource availability. This refresh will include a review of the need for continued deployment of a rapid response vehicle when an ambulance arrives. • We are improving the training and mentorship model for the CCC and have recruited staff internationally to increase clinical support in the room. Improvements made to road operations: • To provide additional senior leadership for our operational workforce, we have recruited a Chief Paramedic who sits on the Trust Board. • As part of “Fit for the Future” we have put revised recruitment and retention plans in place to improve our staffing numbers and ensure the right staff are in the right posts to meet demand. In addition, we have undertaken a rota review and the majority of the new rotas are now in place • We appointed a People Promise Manager and started exemplar programmes to improve retention of frontline staff. Retention ensures that staff turnover is reduced, and we maintain a skilled workforce with knowledge and experience. • We increased our paramedic apprenticeship numbers to increase the number of clinical staff that can respond to patients. • We have reviewed the skill level of crews that are on our ambulances to ensure we have the appropriate skill mix on every resource depending on the incident they are being tasked to. We now have two types of resources, clinical and non-clinical, which are dispatched to patient’s dependent on their needs. • We have increased the level of support and supervision we provide to newly qualified paramedics. • Specialist Practitioners are used to provide additional clinical support and increase the use of other care pathways as an alternative to hospital conveyance where this would better suit the patient’s needs. • The new joint process with our healthcare partners in relation to the amount of time an ambulance crew will wait at a hospital to handover their patient that was discussed at the inquest hearing has been successfully implemented with all hospitals within the SCAS geographical area. This has resulted in our Category 2 response times improving by 6 minutes to an average of 24 minutes in January and February 2025. Improvements made to our fleet of vehicles: • We are in the process of updating our fleet of vehicles to increase the reliability of our fleet and reduce occasions where vehicles are out of service or break down during operational use. A total of 124 new vehicles have been ordered, with 53 delivered by the end of 2024. 2 I hope that this letter has adequately addressed the concerns that you have raised. Please do let me know if you would like to be kept updated on the progress of our improvement programme. Should you wish to discuss these matters further, please contact Legal Services at SCAS who will be able to arrange a time for us to meet. , Head of Yours sincerely, Chief Executive 3
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