Source · Prevention of Future Deaths

Reginald Dixon

Ref: 2017-0214 Date: 18 Sep 2017 Coroner: Zafar Siddique Area: Black Country Responses identified: 1 / 1 View PDF

An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.

Date 18 Sep 2017

56-day deadline 13 Nov 2017

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.

View full coroner's concerns

1. Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level 3. The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time.

2. Evidence also emerged during the inquest that there were insufficient resources available and average response times of 29 minutes. This delay posed a risk to patients.

Responses

1 respondent

West Midlands Ambulance Service NHS / Health Body

PDF

Action Taken

West Midlands Ambulance Service has provided further education and refresher training around head injuries during NHS Pathways updates. The Trusts Director of Clinical Commissioning and Service Development has also written to the Clinical Commissioning Group regarding resourcing provision, including the Preventing Future Death report. (AI summary)

View full response

Dear Mr Siddique Thank you for your letter attaching the report to prevent future deaths. Please find our response below. Matter of concern
- Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level
3. The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time. Response
- The second 999 call had failed the audit completed against the Pathway system. The audit identified that the call assessor did not fully establish during the call the level of consciousness of the patient, further probing was required, due to the lack of probing on the call It is unclear whether the category 3 response which was generated was appropriate. As the category of call disposition depends on the answers provided by the caller it is not possible to determine whether this call would have generated a category 2 response. Action should be taken
- You may wish to consider further training of those staff involved in triaging response calls given the issues identified, Response
- Pathways is a national triage tool used by VVMAS to categorise 999 calls, our call assessors are not clinically trained therefore are guided by Pathways and the answers they gain from the caller in relation to the disposition of the call. Pathways provides its national training package to WMAS tutors. who in turn provide training to our call assessors. Pathways annually quality assesses our lead Tutor. who is then required to assess all WMAS tutors. Following this sertous ,nc,dent WMAS have ncIuded further education and refresher training around head injuries durhg NHS Path:;ays pdaie due to take place n o obc’ v rb

Response
- The number of ambulances on duty is done on historic demand data along with local intelligence. Resourcing is matched against a presumed demand profile. On this date resourcing for the Black Country division was above the predicted demand level. Despite this extra resourcing the demand experienced on the ambulance service during the time of this incident outstripped the available resources. Actions should be taken
- You may wish to consider further consultation with the Clinical Commissioning Group(s) in relation to the level of resource provided to deal with the Black Country population in light of insufficient resources being available in a timely manner as identified during this inquest. Response
- The Trusts Director of Clinical Commissioning and Service Development/ Executive Nurse has personally written to the Clinical Commissioning Group over the current resourcing provision and has included within that letter the Preventing Future Death report. Please find attached the letters of communication for your information.

Report sections

Investigation and inquest

On the 10 July 2017, I commenced an investigation into the death of the late Mr Reginald Dixon. The investigation concluded at the end of the inquest on 4 September 2017. The conclusion of the inquest was a short form conclusion of accidental death.

The cause of death was:

1a Aspiration Of Gastric Contents b Subdural And Traumatic Subarachnoid Haemorrhage c Skull Fractures And Cerebral Contusions II Systemic Hypertension, Left Clavicle, Left Rib And Left Neck Of Femur Fractures

Circumstances of the death

i) On the 26th June 2017 at 1853 hours a 999 call was received by West Midlands Ambulance service (WMAS) to reports of a 70-year-old male, Mr Dixon who had an unwitnessed fall downstairs sustaining a head and back injury. ii) Initially it was reported the patient was conscious and breathing. The location of the incident was in Norton, Stourbridge. The call was triaged through Pathways and a category 3 response assigned. At that time, there was no available resource to immediately assign to the case. iii) At 1921 hours a second 999 call was received for the patient and this to was triaged through Pathways and a category 3 response assigned. It was reported that the patient’s condition had changed and they were now vomiting and becoming drowsy. There was still no available resource to immediately assign to the case. iv) At 1931 hours a third 999 call was received for the patient and it was reported that the patient’s condition had deteriorated further and following triage a category 2 response assigned. An ambulance was assigned to

[IL1: PROTECT] the case within 4 minutes but was some distance away from the incident. v) At 1945 hours a fourth 999 call was received and during this call the ambulance arrived on scene at 1950 hours, 57 minutes from the time of the original call. vi) The patient was found by the ambulance crew with a lowered conscious level and multiple injuries. Following assessment, the patient was conveyed to the major trauma centre during the transfer the crew were intercepted by the MERIT team, who anaesthetised the patient prior to continuing to hospital. vii) He was taken to Queen Elizabeth Hospital, Birmingham where it was identified the patient had an un-survivable head injury and wasn’t deemed suitable for neurosurgery and sadly passed away the same day.

Action should be taken

1. You may wish to consider further training of those staff involved in triaging response calls given the issues identified.

2. You may wish to consider further consultation with the Clinical Commissioning Group(s) in relation to the level of resource provided to deal with the Black Country population in light of insufficient resources being available in a timely manner as identified during this inquest.

Copies sent to

Senior Coroner Black Country Area

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0214
Date of report: 18 September 2017
Coroner: Zafar Siddique
Coroner area: Black Country

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: 13 Nov 2017.

Sent to

West Midlands Ambulance Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.