Source · Prevention of Future Deaths

Christopher Williams

Ref: 2019-0183 Date: 31 May 2019 Coroner: Yvonne Blake Area: Norfolk Responses identified: 1 / 1 View PDF

The report highlights an ambulance arriving outside of Trust guidelines, a call handler's failure to escalate the patient's worsening condition and incorrect algorithm use, and a communication breakdown about an arranged hospital bed, potentially delaying treatment.

Date 31 May 2019

56-day deadline 26 Jul 2019

Responses identified 1 of 1

Emergency services related deaths (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. : _ (1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.

(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm (3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department; despite a bed already arranged several hours before by the GP This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis. Trust's Business Continuity Manager was unaware until inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP's concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust's triaging system , placing patients at risk: In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams' worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system) , were reluctant to add a neurological algorithm, the reason for this is unclear: When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant: It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about prior to inquest: Again; this failure in communication is one which feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are systemic failures within your organisation which should be addressed. having The The the the this,

Responses

1 respondent

East of England Ambulance Service NHS Trust NHS / Health Body

10 Jul 2019 PDF

Action Taken

East of England Ambulance Service NHS Trust has recruited 491 frontline staff and has a further 270 frontline offers of employment in process. They are also in communication with the CAD supplier to allow pertinent information to be transferred from the original call into the new call. As an interim arrangement dispatch staff will ensure pertinent information is transferred into the new call. (AI summary)

View full response

Dear Ms. Blake, Re: Regulation 28 Christopher Williams (31st
2019) am writing to you following the inquest of Mr Christopher Williams and the Trusts receipt of Regulation 28. In order to address your concerns, as outlined in Section 5, will outline the Trusts current position and areas which are considered for changelbeing changed: The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines_ Following a review in April 2017 commissioned by NHS England and NHS Improvement recommendations were made on the best service model, pricing review, capacity and demand analysis and the commissioning/contract model The review was undertaken by Deloittes and ORH, a company specialising in operational modelling for emergency and health services. The findings were published on the 11th May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand This was factored in to our emergency operations contract with funding released to enable to increase front line staff by 330 full time equivalents by 2020/21.- To date the Trust have recruited 491 frontline staff with a further 270 frontline offers of employment in process: To support timely release of Trust resources from hospital sites the Trust has worked with system partners to ensure early escalation of hospital handover delays which is supported in a regional handover protocol and operating procedure The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm: Emergency Call Handlers work triage system called Medical Priority Dispatch Solution (MPDS): This system is designed and owned by the International Academy of Emergency Dispatch (IAED) We work with the IAED to improve standards of triage and to also identify where protocol does not meet the needs of patients, whilst also understanding that in an emergency environment where 999 calls are triaged by non-clinicians there will be some calls which will need clinical supportl/ intervention in reviewing the response_ The Trust's Audit and Training Manager will be shortly meeting the IAED's UK Manager; following which the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify neurological deficit pathway which could be used in the triage of 999 calls_ Interim Chief Executive: Dorothy Hosein Chair: Sarah Boulton WWweastamb nhs uk May being using

This proposal will also be sent through to the National Ambulance Services Medical Directors (NASMeD) for their consideration and support: In the case of Mr Williams, whilst there was no protocol which addresses neurological deficit; this had no negative detriment to the care provided or the response assigned by the AOC as the highest level of response was achieved (Category 1): As stated in (report we have re-enforced the escalation process in the initial training with Call handlers and also through a series of 1-2-1 sessions with existing staff. When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams investigated and treated which may have contributed to his death by sepsis_ In the initial call the HCP called and asked for the patient to be conveyed to the Norfolk and Norwich University Hospital, the clinician requested for the patient to be taken to the Emergency Assessment Unit. When we received 999 call from the property identifying that the patient's condition had deteriorated the dispatcher allocated on the new call as it was of a higher priority, in line with 20180525 Ambulance System Indicators_ Due to the dispatcher assigning to the new call it is apparent that information pertaining to the destination of the patient was omitted as the information is sent to the crew using data: We are in communications with the CAD supplier to make an alteration to the duplication process which would allow pertinent information to be transferred from the original call into the call which EEAST are "running on" Having a technical solution will minimise risk of human error: As an interim arrangement we will ask all dispatch staff to ensure that any pertinent information of this kind is transferred into the new call, until there is a technological resolution in place. We are also working with our colleagues in other Ambulance Services who use the same CAD to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources. Should you have any further questions or if you would like any of the areas outlined above expanded upon please do not hesitate to contact me. Please also contact me if you would like to accept the offer to visit the Emergency Operations Centre to arrange a date and time that suits you and staff' s needs. Kind regards, Dorothy Hosein Interim Chief Executive Interim Chief Executive: Dorothy Hosein Chair: Sarah Boulton wwweastambnhs uk being your

Report sections

Investigation and inquest

On 30 January 2019 commenced an investigation into the death of Christopher Williams aged 77 years_ The investigation concluded at the end of the inquest on 22 2019. The conclusion of the inquest was concluded with a narrative conclusion and the medical cause of death given as: 1a) Multi-Organ Failure 1b) Sepsis Ic) Infected Post-Op Wound (Staph Aureus) 2 Obesity, Immobility and Hypertension:

Circumstances of the death

Mr Williams underwent a procedure on 19 January 2019 t0 remove a screw from a previous foot surgery because of infection developing around the site_ He had a popliteal nerve block and the procedure was uneventful: Two days later on the 22 January 2019 he developed severe pain in that leg making it impossible for him to weight bear. He called the surgeons secretary and was advised to call his GP which he did. He had also developed paraesthesia to both legs worsening back pain. His GP attended and requested an urgent ambulance since she was concerned about cauda equina. She also arranged for him to be admitted directly to the ward at the NNUH. She called the ambulance service at 14.1-she was told it may take up to four hours, a pick-up time of 15.17 hrs was entered. At 15.20 hrs the Trust called the patient back and was told that his condition was worsening, however the call handler did not escalate this information within the control centre and thus no-one else was aware. It is understood that the call handler also used an incorrect algorithm (haemorrhage) which led to the wrong_questions used A further welfare call was made at 17:4Ohrs but no answer May day and 7hrs, being received so this was escalatedto the Duty Officer who subsequently upgraded the call to a grade 3. At 19.41 hrs made a 999-call describing Mr Williams not being alert and difficulty in breathing and the call was upgraded to a category 1_ A RRV and DSA were dispatched at 19.45hrs and arrived on scene at 19.58 and 20.01hrs respectively Mr Williams was conveyed to the NNUH arriving at 20.59hrs. He was then kept in the ambulance until 23.56 hrs when he finally entered the Emergency Department: He was admitted to a surgical ward after preliminary investigations by the Emergency Department and orthopaedic doctors with a working diagnosis of possible pulmonary embolus_ His condition worsened rapidly on morning of the 23 January 2019 with hypoxia, acute kidney injury and Iow consciousness_ The opinion was that he had sepsis with worsening heart failure. He was admitted to High Dependency Unit but despite intensive treatment he died on the 26 January 2019.

Action should be taken

In my opinion action should be taken t0 prevent future deaths and believe you and the East of England Ambulance service NHS Trust have the power to take such action.

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Shared signals

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Report details

Reference: 2019-0183
Date of report: 31 May 2019
Coroner: Yvonne Blake
Coroner area: Norfolk

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: 26 Jul 2019.

Sent to

East of England Ambulance Service

Part of a series

2 reports

2014-0131 0 responses identified

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Data: judiciary.uk under OGL.