Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 19 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Aug 2018 |
|---|---|
| Deceased | David Sweeney |
| Coroner | Me Hassell |
| Coroner area | London Inner (North) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
David Anthony SWEENEY (died 25.04.15)
THIS REPORT IS BEING SENT TO:
1. Dr Fionna Moore
Chief Executive
London Ambulance Service NHS Trust
220 Waterloo Road
London SE1 8SD
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 April 2015, I commenced an investigation into the death of David
Sweeney, aged 28 years. The investigation concluded at the end of the
inquest yesterday. I made a determination at inquest as follows.
“David Sweeney’s death was alcohol related.
An opportunity for earlier medical intervention – which might have saved
him on this occasion – was lost when a call to the ambulance service was
not categorised as a priority.”
The medical cause of death was:
1a hypoxic brain injury
1b acute alcohol toxicity
1
4
CIRCUMSTANCES OF THE DEATH
A member of the public called London Ambulance Service at 4.47pm on
18 April 2015, to report that he could see a man [Mr Sweeney] lying on
the ground vomiting. The caller said that the man had been unconscious.
In response to the LAS emergency medical despatcher’s question asking
if he was now a little bit awake, the caller replied yes.
The EMD then incorrectly selected the protocol for a sick person instead
of the protocol for an unconscious person, and so the call did not receive
a categorisation of red 2, target arrival time of 8 minutes, which it
otherwise would have done.
Instead, a clinical adviser rang back, categorised it as a C1, and an
ambulance arrived 1 hour 40 minutes after the original call, prompted
then by a call from the Metropolitan Police Service who had come upon
Mr Sweeney.
Just a few minutes before LAS arrived, Mr Sweeney suffered a cardiac
arrest and consequent hypoxic brain injury, from which he died a week
later.
One of the intensive care consultants who looked after Mr Sweeney in the
following days, gave evidence that if Mr Sweeney had been in hospital at
the time of his cardiac arrest, he probably would have survived.
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.
A call to the London Ambulance Service regarding a man who had been
unconscious did not prompt a red prioritisation.
You will remember that I wrote to you on 27 May 2015, regarding the
assumption made by an LAS EMD that a child was asleep but rousable,
when in fact the little boy was likely to have been unconscious.
I am extremely concerned that a theme may be emerging in the handling
by LAS of calls regarding unconscious patients.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 19 October 2015. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Association of Ambulance Chief Executives (AACE)
National Ambulance Service Medical Directors (NASMeD)
Professor Dame Sally Davies, Chief Medical Officer for England
NHS England
, consultant in intensive care
, Ms Mary McCarthy, sisters of David Sweeney
, wife of David Sweeney
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
19.08.15
3
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