Source · Prevention of Future Deaths

Sarah Gilbert-Jones

Ref: 2022-0037 Date: 4 Feb 2022 Coroner: Graeme Hughes Area: South Wales Central Responses identified: 1 / 1 View PDF

Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.

Date 4 Feb 2022

56-day deadline 1 Apr 2022

Responses identified 1 of 1

Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards) Mental Health related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

(1) When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it was accepted that he explicitly indicated to the Call Handler that the deceased had taken an overdose of, inter alia, tablets. Based upon that, & answers to other questions posed by the call handler, the call handler selected a protocol which did not appear to require this crucial piece of information to be either recorded within it, or to form part of the material which led to the categorisation of the call for the purposes of determing the appropriate response. In short, it led to a categorisation which could only loosely provide a response (based upon the level of demand that evening) estimate of around 3 hours. The concern here is that treatment for a massive overdose is time critical, & the processing of the call did not appear to accurately reflect the peril the deceased was then in, nor the importance of providing an acute emergency response.

(2) There appeared to be an opportunity shortly following the initial categorisation of the response, by a clinical floor walker, to upgrade to a code/categorisation which would likely have led to a swifter response, but an under-appreciation, or otherwise, of the then time critical treatment window open to the deceased. I was informed in evidence that the clinical floor walker would have had access to TOXBASE via the Clinical Support Desk at that time, & had that been accessed & information promptly secured regarding the treatment indicated, this would have alerted the clinician to the need for an acute emergency response. This was subsequently undertaken by the attending paramedic (albeit not via TOXBASE) some hours later, & who immediately after having accessed the treatments for massive overdose, appreciated that the deceased was a time sensitive patient & to convey to the emergency department with all haste.

(3) Following the second call to Clinical Contact Centre at 23.48 on 28.10.20, there were somewhat bewilderingly complex, & inconsistent categorisations of the code for response which appeared to lead to response vehicles being despatched or stood down, whilst the patient remained in need of time sensitive treatment by way of transfer to an Accident & Emergency Unit. Whilst I was assured that this had been addressed by learning & guidance to call handlers, a review of categorisations, coding’s & actions in the setting of a patient demonstrating the symptoms as per the deceased on 28/29 October 2020 to achieve clarity/consistency is invited.

Responses

1 respondent

Welsh Ambulance Service NHS Trust NHS / Health Body

31 Mar 2022 PDF

Action Planned

The Welsh Ambulance Services NHS Trust is considering a specific question set within the Medical Priority Dispatch System (MPDS) to identify propranolol overdoses, and has an existing Standard Operating Procedure for flagging overdose cases to dispatchers. The trust is also proposing further actions outlined in an attached plan. (AI summary)

View full response

Dear Mr Hughes Sarah Marie Gilbert-Jones I write in response to the Prevention of Future Deaths Report issued to this Trust on the 4 February 2022, following the inquest in relation to Sarah Marie Gilbert-Jones. I understand that, whilst giving evidence, my staff provided you with details of changes that the Trust has already made (since this incident), that would have affected how we respond to such a call received today. I will not repeat that information here, but rather build on those changes. The issue of Propranolol overdose has already been discussed at the International Academies Of Emergency Dispatch (IAED) Clinical Focus Group, initially raised by another ambulance service. This is not an issue being faced here in Wales alone. One consideration has been as to whether there is a specific question set, with associated code group and priorities, which will identify the case as a propranolol overdose. The Medical Priority Dispatch System (MPDS) already has a question set that relates to Fentanyl which was an issue in some countries. The issues of instigating different actions for different drug types are twofold. There is the fact that the individual drugs that can be involved in overdose cases are many and varied. Additionally, this moves away from the basis of the Trust’s Clinical Response Model, where the sickest patients are identified and attended first. This Model is based on the patient’s condition at the time and is not based on potential future changes to their conditions.

2 During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident.

That flag identifies the case as an overdose of such things as Propranolol, and is visible for the staff responsible for dispatching vehicles. This flag indicates to the Allocator that a vehicle should be sent as soon as possible and that allows the dispatch teams to consider allocating available resources out of time order (as resources are normally dispatched to the highest priority/oldest call first).

I attach for your reference a plan that lists the actions the Trust is proposing to consider in order to address the issues highlighted within your Regulation 28 report. Any changes made will be included within the Trust’s Standard Operating Procedures (Clinical Contact Centre and Clinical Support Desk).

Whilst writing I would like to extend my sincere condolences to Miss Gilbert-Jones family on their sad loss. I am pleased to hear that they have accepted the Trust’s offer to reconsider this matter under the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continuance improvement to support the prevention of future deaths.

Report sections

Investigation and inquest

On 3.11.20, I commenced an investigation into the death of Sarah Marie GILBERT-JONES. The investigation concluded at the end of an inquest on 3rd February 2022. The conclusion of the inquest was:- The deceased died due to the direct effects of a significant and deliberate overdose of her prescription medication. It is unlikely that she intended the consequences of that overdose to be her own death. It is likely that the timing of her death was contributed t o by her sub-optimal transfer to hospital, narrowing the opportunity for administering effective life-saving medication and treatment. The cause of death being: 1a: Toxicity

Circumstances of the death

These were recorded as :- Since 2019, Sarah Marie GILBERT-JONES, had experienced fluctuating and worsening mental health. This had manifested itself in episodes of self-harm, and from the summer of 2020 overdoses of her prescription medication. On the evening of 28.10.20 she has taken a significant overdose, concurrently with a large quantity of alcohol. A delay in the arrival of the emergency services compromised an opportunity for earlier life-saving treatment. She died in the early hours of 2910.20 at the Royal Glamorgan Hospital. The cause of her death due directly to the toxic effects of the overdose. The Inquest broadly focused upon:-
a. The emergency response following notification of the overdose & request for ambulance assistance. In particular, the grading of calls to the Clinical Contact Centre & the actions initiated following the same
b. Whether a delay(s) in ambulance service attendance (upon the deceased) & conveyance to an Accident & Emergency Department, contributed to her death c. The contribution, if any, of sub-optimal Mental Health Services provision upon her death

Copies sent to

and the Health Inspectorate Wales, Cwm Taf Health Board

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Shared signals

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Report details

Reference: 2022-0037
Date of report: 4 February 2022
Coroner: Graeme Hughes
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Apr 2022.

Sent to

Welsh Ambulance Service NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.