Levi Alleyne

Coroner's concerns

AI summary

Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.

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According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
• unnecessary delay to life-saving treatment being given due to the fear (well founded or otherwise) that OHPLs are still live,
• or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live. As a result of the inquest, SSEN and SCAS introduced new procedures to ensure the electrical risk is reduced in the shortest time possible whilst taking into account the time and resource pressure on SCAS when dealing with emergency situations.
1) SSEN has provided SCAS with a map of England and Wales containing direct emergency numbers for each DNO and which areas it covers.
2) SCAS has changed its Standard Operating Procedure to include an instruction for an operator, during a 999 call, to ask a nearby operative to contact the DNO if scene safety is compromised due to electrical hazards.
3) SCAS Critical Systems Manager has created a process within CAD that, when clicked, will launch the website and map provided by SSEN. However, there is no guarantee that a similar procedure or other mitigating measures will be adopted across England and Wales and so there remains a risk of future deaths.

Responses

4 respondents

Energy Networks Association

8 Dec 2022 PDF

Action Planned

ENA has asked each DNO and TNO member company to check that emergency services have contact details and know how to respond to incidents; ENA will open dialogue with the HSE to see whether it can support them to further enhance awareness and will review and update its safety leaflet - Safety advice for the Emergency Services. (AI summary)

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Dear Ms Thorne,

This letter is the response from Energy Networks Association (‘ENA’) to your Regulation 28: Report to prevent future deaths, dated 4th November 2022.

We would like to begin by sharing that we are deeply saddened by the tragic death of Levi Louis Alleyne and want to express our deepest sympathies and extend our condolences to his family and friends.

ENA was not represented (and did not participate) in the inquest which you held in this case, but we are happy to try to address the concerns you have identified.

ENA represents the companies which operate the electricity wires, gas pipes and energy system in the UK and Ireland. We help our members meet the challenge of delivering electricity and gas to communities across the UK and Ireland safely, sustainably, and reliably. Our members’ duties are enshrined in many legislative provisions and in regulatory licence conditions issued by Ofgem, the industry regulator.

Our members include every major electricity and gas distribution network operator in England and Wales including some independent network operators and National Grid Electricity Transmission. For the purpose of this response, we are focussing on the electricity Distribution Network Operators (DNO) and Transmission Network Operators (TNO) in England and Wales.

ENA has considered your concerns as expressed within your report and we wish to share with you the actions ENA and its members are implementing with an aim to prevent similar future events from occurring.

As a result of the immediate actions undertaken by SSEN and South-Central Ambulance Service (SCAS) as documented within your report, on 8th November 2022 ENA met with all DNO and TNO member companies.

Ms Katy Thorne KC

8 December 2022

-2-

ENA has asked each DNO and TNO to check and confirm that suitable and effective arrangements are in place to regularly communicate on an annual basis, their overall network boundaries at a regional level or equivalent with their local emergency services. This will help maintain awareness of the appropriate DNO and TNO to be contacted in the event of an emergency involving overhead powerlines (OHPLs).

I can confirm that this review will be completed as soon as reasonably practicable and, in any event, no later than 31st January 2023. I will write to you again to confirm when this has been done.

ENA continues to promote awareness of the dangers associated with electricity networks with third parties and members of the public through its Public Safety Committee (‘PSC’) which includes the Health and Safety Executive (‘HSE’). This includes promoting:

- best practice guidance such as ENA’s ‘Look Out, Look Up’ campaign material.
- HSE’s Guidance Note GS6 Avoiding danger from overhead power lines and the need for third parties to undertake a risk assessment when working in the vicinity of OHPLs.
- the industry’s 105 number (for reporting or gaining information relating to power cuts and to report safety concerns with electricity network assets) as another route for third parties to report safety incidents and receive advice. o It is relevant to note that 105 is a simple number to remember which enables anybody, based on phone number matching with location of telecommunication masts, to automatically be put through to the local network operator (DNO) who can give relevant help and support. However, it does not and should not replace 999 as the primary route for reporting emergencies in which there is an immediate risk to life.

ENA has great respect for the work of the HSE and our relationship is a constructive one borne from shared goals. We will open dialogue with the HSE to see whether we can support them to further enhance contractor/site manager awareness through the HSE’s guidance publications to industry and increase industry awareness of the emergency 105 number.

Referencing the concerns set out in your report, ENA will also review and update accordingly its safety leaflet entitled - Safety advice for the Emergency Services. Again, this will be completed by 31st January 2023 at the latest and I will write to let you know when it has been done.

Finally, we will also undertake an assessment of any changes or improvements that can be made to how we communicate with the public to promote the awareness of the dangers associated with electricity assets in the public domain.

We hope that you find this response provides a level of reassurance that ENA and its members have considered your concerns and we intend to take proactive steps to address the concerns you have identified in your Regulation 28 Report.

NHS England NHS / Health Body

14 Dec 2022 PDF

Noted

NHS Digital explains the function and governance of NHS Pathways, noting that standard operating procedures and contact numbers are the remit of local service providers and do not fall under NHS Pathways' responsibility. (AI summary)

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Dear Ms Thorne NHS Digital Response to Prevention of Future Deaths Report - Inquest touching the death of Levi Louis Alleyne

I am writing in response to the Prevention of Future Deaths Report received from HM Coroner, dated 4th November 2022. This follows the death of Levi Louis Alleyne who sadly passed away on 16 November 2020. This was followed by an investigation and inquest which concluded on 3rd October 2022. NHS Digital were not aware that this inquest was occurring, and therefore we did not have the opportunity to provide information to assist your inquiry.

Firstly, I would like to offer my sincerest condolences to the family of Levi Alleyne.

I am and am writing in my capacity as Clinical Director, NHS Pathways, NHS Digital.

NHS Pathways is the clinical decision support software (CDSS) used by all 111 service providers, and some 999 ambulance trusts in England. For information, we have included a short summary of the functions that NHS Pathways performs and the governance that underpins it (containing background information on NHS Pathways) in Appendix A.

HM Coroner has raised a number of matters of concern in the Regulation 28 Report. None of these directly reference NHS Pathways, but we believe concerns 4 and 5 are the most applicable. We have set out below relevant information about NHS Pathways, and NHS Digital’s role.

enquiries@nhsdigital.nhs.uk

1) Standard operating procedures and DNO contact numbers

NHS Pathways remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations. Standard operating procedures relating to a range of operational requirements are locally set by 111 and 999 providers. NHS Pathways is a clinical decision support system and more operationally focused content such as how to contact a utility provider sits outside the remit of the NHS Pathways system.

2) NHS Pathways assessment of electrocution, including where there are scene safety concerns

NHS Pathways is a clinical triage system which provides the means to assess a patient's clinical presentation at the time of the call and signposts to the care skill set and time frame that a patient requires at that point in time. There are 2 main routes within the NHS Pathways system where electrocution from a non-domestic hazard (such as overhead power lines) can be identified:

1) following identification of cardiac arrest, which leads straight to a Category 1 ambulance disposition being reached, the system seeks to establish if the scene is safe. If a negative (‘no’) response is given the ‘unsafe’ route asks whether an electrical hazard is present.

2) via the major trauma route in Module 0, if it has been identified that the patient is conscious (as occurred initially with the deceased in this case). The route asks questions about the nature of the trauma and if the option for ‘electrical injury’ is selected the NHS Pathways system asks whether the shock was caused by a non-domestic supply. If so this generates a Category 2 ambulance.

Following either of the above routes being followed the NHS Pathways system makes a further assessment of scene safety. If ‘the scene is unsafe’ is selected, this prompts identification of an electrical hazard. There is further questioning about whether the electrical hazard has been made safe. In the case of a non-domestic electrical hazard that hasn’t been made safe, further advice presents where the caller is advised;

• Not to put themselves at risk

• Not to go closer than 20 yards as high voltage electricity can jump

• Keep away from liquid spills, wet floors and puddles due to the conduction of electricity in water.

enquiries@nhsdigital.nhs.uk

There are also system prompts for the Health Advisor to consider whether the situation also requires the attendance of other emergency services for any type of electrical hazard that has the potential to make the scene ‘unsafe’. Although such tragic incidents are rare, NHS Pathways are fully supportive of identifying any further learning from this case and are currently reviewing the scene safety elements within the triage system. The initial discovery has commenced, and any identified changes would be subject to review and sign off from the National Clinical Assurance Group and, if relevant, from the Emergency Call Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS England and Department of Health & Social Care (DHSC) on issues of ambulance call prioritisation. Its principal remit is to recommend which disposition codes should be mapped to which ambulance responses. The group consists of membership from Association of Ambulance Chief Executives (AACE), College of Paramedics, NHS England, DHSC, NHS Digital, AMPDS, National Ambulance Commissioning Network (NACN), NASMeD and ambulance Heads of Control.

Conclusion
• NHS Pathways assesses symptoms presented at the time of the call and signposts to the care skill set and time frame that a patient requires at that point in time. NHS Pathways identifies electrical hazards and advises callers on scene safety.
• NHS Pathways remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations.
• The NHS Pathways content is continually under review to take account of clinical issues, user feedback, the latest available data and evidence, guidelines from Royal Colleges and other respected bodies and Coroner feedback. Any changes to NHS Pathways clinical content are overseen by the National Clinical Assurance Group and Coroner referrals are submitted to the National Clinical Assurance Group as a standing agenda item.

NHS Digital takes its role in such enquiries and any Prevention of Future Deaths Reports received very seriously. I would like to take this opportunity again to offer my sincere condolence to Levi Alleyne’s family. If I can be of any further assistance, please contact me.

AACE Other

4 Jan 2023 PDF

Action Taken

AACE shared South Central Ambulance Service NHS Trust's updated SOPs, including a map and contact details for electricity Distribution Network Operators, across all NHS ambulance services. They are also discussing the matter with all Heads of Emergency Operations Centres. (AI summary)

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Dear Katy Thorne KC PREVENTING FUTURE DEATHS: LEVI LOUIS ALLEYNE The Association of Ambulance Chief Executives (AACE) has recently received the above PFD, following the investigation and inquest in relation to the death of Levi Louis Alleyne who died on 16 November 2020. Please note, AACE is a membership organisation, subscribed to by all UK NHS ambulance services, and as such can offer guidance, encourage collaboration across services, and represent sector views, but cannot mandate action. I can confirm that actions taken by South Central Ambulance Service NHS Trust, to update their Standard Operating Procedures (SOPs) following the inquest, have been shared across all NHS ambulance services, including a map and the appropriate contact details for each of the electricity Distribution Network Operators. In addition, to reinforce the required steps, the matter is being discussed with all Heads of Emergency Operations Centres at their meeting in January 2023. We hope very much that this will improve the response to these types of incidents and prevent any delay in patients receiving necessary treatment on scene. I hope this provides sufficient information for you in response to the PFD report. On behalf of AACE, I would like to extend our sincere condolences to the family of Levi Alleyne.

Health and Safety Executive Regulator / Inspectorate

12 Jan 2023 PDF

Action Taken

HSE shared concerns with the Care Quality Commission (CQC) and Healthcare Inspectorate Wales (HIW), the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee, and the Energy Networks Association (ENA), who have requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis; the ENA is currently reviewing their information leaflet on Safety Advice for the Emergency Services. (AI summary)

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Dear Katy Thorne KC, Re: Prevention of future deaths report - Levi Louis Alleyne Thank you for your Regulation 28 report to prevent future deaths issued following the inquest into the death of Levi Louis Alleyne. In this report, you highlighted that the potential for future deaths was two-fold:
1. Unnecessary delay to life-saving treatment being given due to the fear that overhead power lines (OHPL) are still live, and
2. Potentially by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live. In relation to the first concern, in England the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents. This means that delays to life-saving treatment for patients provided by the ambulance service in England would fall within the remit of CQC and not HSE. We have therefore shared this report with CQC to consider. In Wales, the Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of healthcare. HIW’s core role is to review and inspect NHS and independent healthcare organisations in Wales to check that patients, the public, and others are receiving safe and effective care which meets recognised standards. The Memorandum of Understanding between HIW and HSE sets out our roles and responsibilities in further detail. As this would fall within HIW’s remit, we have shared this report with them.

2 In relation to the second concern, the Association of Ambulance Chief Executives (AACE) have advised that actions taken by South Central Ambulance Service NHS Trust following the inquest, including to update their Standard Operating Procedures (SOPs), have been shared across all NHS ambulance services. This includes a map and the appropriate contact details for each of the Distribution Network Operators (DNOs). This matter is due to be discussed further with all Heads of Emergency Operations Centres at their meeting in January 2023. HSE has also shared these concerns with the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee to ensure all emergency services are aware and check they have suitable procedures in place to deal with incidents involving equipment on the electricity network. We have contacted the Energy Networks Association (ENA), who have advised that DNOs and Transmission Network Operators (TNO) have suitable and effective arrangements in place with their local emergency services providers. This includes ensuring that emergency services have suitable emergency contact details for their DNO and that they know how to respond to an incident involving equipment on the electricity network. In future, the ENA has requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis. The ENA are currently reviewing their information leaflet on Safety Advice for the Emergency Services. HSE has commented on the draft document and the review is due to be completed by the end of January 2023. I hope this clarifies the situation but please let me know if you need anything further.

Report sections

Investigation and inquest

On 23 November 2020, I commenced an investigation into the death of Levi Louis Alleyne age 41. The investigation concluded at the end of the inquest on 3rd October 2022. The conclusion of the inquest was accident. The medical cause of death was electrocution.

Circumstances of the death

1. Levi Louis Alleyne died on 16th November 2020 at Bartletts Farm by electrocution while pursuing his occupation as a grab lorry delivery driver.
2. He had been hired to deliver material to a building site where Overhead Power Lines were sited. No warnings, verbal or visual, were provided to him about the presence of the Overhead Power Lines [OHPLs]. He reversed his lorry onto the site and raised the crane arm of his grab lorry directly under the OHPLs. The electricity arced onto the crane arm, through the lorry and into Mr Alleyne.
3. Scottish and Southern Electricity Networks [SSEN] were the local Distribution Network Operator [DNO]. An automatic protection system on the OHPLs operated within a few seconds to isolate the relevant section of the overhead power line, which cut off the power to one of the lines.
4. A bystander rang 999 at 1133 hours and expressed his reluctance to approach Mr Alleyne due to the risk of electrocution. The South Central Ambulance Service [SCAS] operator, who did not know whether the power lines were still live or not, advised him not to approach. For this reason, no CPR was administered until the Air Ambulance arrived.
5. Although there had been no confirmation that the electricity was now safe, Air Ambulance personnel picked up Mr Alleyne and administered CPR from 1152, but despite their efforts, Mr Alleyne died at the scene.
6. After calling 999, at 1146 hours, the bystander contacted Scottish and Southern Electricity [SSEN] who shut off the electricity to all three of the power lines.
7. At 1150, the SCAS operator attempted to contact SSEN but did not get through for 9 minutes.
8. At 1202 SSEN confirmed to SCAS that the power was off.

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