Source · Prevention of Future Deaths
Philip Hayes
Ref: 2019-0363
Date: 30 Oct 2019
Coroner: Karen Dilks
Area: Newcastle upon Tyne
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryDelays in ambulance response for a C2 call and a lack of re-assessment for a deteriorating patient after multiple calls were noted. The coroner also raised concerns about inconsistencies in triage algorithms, clinical input referrals, and health advisor training.
Date
30 Oct 2019
56-day deadline
3 Feb 2020 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
Delays in ambulance response for a C2 call and a lack of re-assessment for a deteriorating patient after multiple calls were noted. The coroner also raised concerns about inconsistencies in triage algorithms, clinical input referrals, and health advisor training.
View full coroner's concerns
(1) in ambulance dispatch Call categorised C2 received response hour 2 minutes after original call (2) Failure to conduct reassessment f C2 category notwithstanding 5 subsequent calls describing additional symptoms and a deteriorating condition (3) Inconsistency in approach and answers to algorithm question designed to indicate risk of aortic aneurysmlruptureldissection On Delay
Calls triaged by health advisors with limited medical training and no medical qualifications (5) Inconsistency in approach to referral for clinical input (6) Appropriateness of triage by algorithm Insufficient if any Weight given to actual reported symptoms and indicators of a medical emergency
Calls triaged by health advisors with limited medical training and no medical qualifications (5) Inconsistency in approach to referral for clinical input (6) Appropriateness of triage by algorithm Insufficient if any Weight given to actual reported symptoms and indicators of a medical emergency
Report sections
Investigation and inquest
On 24 April 2019 opened an investigation into the death of Philip Richard Hayes aged 60yrs. The investigation concluded at the end of the inquest on 29 October 2019. The conclusion of the Inquest was: Medical cause of death: Aortic dissection Way the
Conclusion: Natural causes
Conclusion: Natural causes
Circumstances of the death
14 April 2019 in or around 13:13 Philip Hayes suffered an aortic dissection; Initial symptoms were chest and flank pain: At 13.13 a 999 call was made to summon urgent assistance. The call was triaged at 13:16 and categorised C2 response (18 minutes): At 13.23, 13.27, 13.31 , 13.45 and 13.59 further calls reporting new symptoms and a deteriorating condition were made. These subsequent calls did not result in a reassessment of the original categorisation nor did the calls result in the case being referred for clinical input. Ambulance technicians arrived at 14.02 and paramedics at 14:15 (1 hour and 2 minutes after the original call) Philip Hayes was transported to the Northumbria Specialist Emergency Care Hospital, arriving at 15.13. His dissection was diagnosed following CT scan at approximately 23.56 when arrangements for his transfer to Freeman Hospital, Newcastle for specialist vascular care were made. Notwithstanding maximal care and treatment he died there on 18 April 2019
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation the power to take such action:
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Report details
- Reference
- 2019-0363
- Date of report
- 30 October 2019
- Coroner
- Karen Dilks
- Coroner area
- Newcastle upon Tyne
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Feb 2020 (estimated from the Judiciary.uk publication date).
Sent to
- North East Ambulance Service