Source · Prevention of Future Deaths
Helen Barker
Ref: 2019-0392
Date: 19 Nov 2019
Coroner: Paul Cooper
Area: Lincolnshire
Responses identified: 0 / 2
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Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.
Date
19 Nov 2019
56-day deadline
22 Feb 2020 est.
Responses identified
0 of 2
Coroner's concerns
Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.
View full coroner's concerns
1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:- Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded?
Report sections
Investigation and inquest
On 21/11/2018 I commenced an investigation into the death of Helen BARKER, aged 50. The investigation concluded at the end of the inquest on 12/11/2019. The conclusion of the inquest was that Helen BARKER died as a result of Alcohol and Drug related, the medical cause of death being: 1a. Acute Ethanol Intoxication 1b. 1c.
2. Drug Toxicity
2. Drug Toxicity
Circumstances of the death
The deceased was a 50 year woman with a history of alcohol and depression. She called the emergency services on the 11th Nov 2018 to report she was feeling suicidal and threating to take an overdose. Reviews were supposedly undertaken at 22.39, 00.30 and 03.43 hours but these did not occur due to pressure at work. The paramedics eventually attended at 04.34 hours some 6 hours and 35 minutes after the initial call was made. The deceased was pronounced dead at her home on 12th November 2018 at 4 Bexon Court, Louth
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Related inquiry recommendations
Report details
- Reference
- 2019-0392
- Date of report
- 19 November 2019
- Coroner
- Paul Cooper
- Coroner area
- Lincolnshire
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Feb 2020 (estimated).
Sent to
- CAT
- East Midlands Ambulance Service