The Nerams Group
Other
Action Taken
Following an investigation into the death of Jack Matthew Shields, The Nerams Group dismissed one employee for gross negligence and terminated another for unrelated reasons. They refreshed competency assessments and CPD for non-registered healthcare professionals reading 12 lead ECGs and circulated information on available backup categories to all staff. (AI summary)
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Dear HM Coroner, I write to you in response to your request for further information, lessons learned and mitigations following the death of Jack Matthew Shields Deceased on the 27th of April 2024. We were notified of this event from the Northeast Ambulance Service following a concern raised against an employee of ours at the time. The concerns surrounded the lack of identification of the clinical presentation of the patient at the time of attendance and that a higher category of backup should have been requested. The crew consisted of a double Technician crew; (Advanced Technician) and
(Emergency Care Technician), both of whom held a level of qualification which should have allowed them to have recognised the presentation and initiate treatment. Upon investigation of the events, it was identified that there were significant failings on the part of which could not be rationally justified. was the senior clinician who was responsible for the patient care. During the hearing, was still unable to identify the concerning features of the case and key features of the ECG when shown to him again, as a result of this and due to another unrelated identified clinical concern, was dismissed due to gross negligence. was also terminated due to unrelated employment reasons. Appropriate referrals to both the Northeast Ambulance Service to allow them to monitor his ongoing employment on their contracts should he attempt to apply for them or work for a different company as well as statutory notifications to the CQC were made immediately following this incident investigation. Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.
Should you require more information, please do not hesitate to contact me directly.
(Emergency Care Technician), both of whom held a level of qualification which should have allowed them to have recognised the presentation and initiate treatment. Upon investigation of the events, it was identified that there were significant failings on the part of which could not be rationally justified. was the senior clinician who was responsible for the patient care. During the hearing, was still unable to identify the concerning features of the case and key features of the ECG when shown to him again, as a result of this and due to another unrelated identified clinical concern, was dismissed due to gross negligence. was also terminated due to unrelated employment reasons. Appropriate referrals to both the Northeast Ambulance Service to allow them to monitor his ongoing employment on their contracts should he attempt to apply for them or work for a different company as well as statutory notifications to the CQC were made immediately following this incident investigation. Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.
Should you require more information, please do not hesitate to contact me directly.