Source · Prevention of Future Deaths

Harry Gill

Ref: 2016-0323 Date: 30 Aug 2016 Coroner: Michael Singleton Area: Blackburn, Hyndburn and Ribble Valley 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raises concerns about the robustness of the NHS 111 vomiting pathway, noting that only one out of four calls received an appropriate response.

Date 30 Aug 2016

56-day deadline 25 Oct 2016 est. estimated from the report date

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The coroner raises concerns about the robustness of the NHS 111 vomiting pathway, noting that only one out of four calls received an appropriate response.

View full coroner's concerns

as follows: That on four of telephone conversations between Mr Gill and his wife and NHS 111 only one call elicited the appropriate response: It would therefore appear that the vomiting pathways is not sufficiently robust to ensure an appropriate response.

Responses

1 respondent

NHS England

NHS / Health Body

Letter dated 11 Oct 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• NHS Pathways concluded a review of its vomiting questions and enhanced their content. • The vomiting questions were amended to include more specific prompts for coffee ground vomit, blood, and faeces. • The site training package for the management of vomiting was further enhanced.

View full response

Dear Mr Singleton am writing in response to a Section 28 ruling from HM Senior Coroner: This follows the tragic death of Harry Gill who passed away on the Znd June 2016. This was followed by an investigation and inquest which concluded on 24/8/2016. am writing in my role as the Clinical Director for NHS Pathways which is the clinical triage platform for the national NHS 111 service. ami BA, MSc, MB ChB (Sheffield). The Coroner has requested that NHS Pathways review its management of the vomiting pathways and report on any improvements that have been made To aid this process NHS Pathways entered into discussions with the Clinical and Quality Lead for the North Western Ambulance Service (NWAS) to better understand their concerns regarding the structure of the vomiting questions. We agreed there was scope t0 enhance our content and commenced a review with our clinical team This review has now concluded and can report the following changes to the vomiting questions with rationale CURRENT QUESTION The current question presented to the call handler and then asked of the patient is; 'Have you vomited blood or faeces? Call handlers at NWAS reported a degree of confusion with the question and not enough supporting information if the patient answered positively. At present call handlers may ask the question as it appears without making full use of existing supporting information to probe directly about coffee ground vomiting, and a caller may not realise that coffee ground vomit is blood Information and technology WWWdigital nhs.uk fo better heait and care enquiries@nhsdigital nhs.uk

NHS] Digital PRQPOSED CHANGES We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate localised gastric bleed. The question that will be asked in the next release of the algorithms will be; Have you vomited any of the following? A1- Coffee ground vomit Supporting information presented to the call handler; This means the individual has brought up or vomited dark brown or black material that looks like soil or coffee-grounds. Blood that has been in the stomach often looks like this A2-Blood Supporting information presented to the call handler; This means any blood visible in vomit_ This also means any blood in or near the mouth: The blood may have been forcefully vomited up or just be oozing or welling from the mouth. A3- Faeces Supporting information presented to the call handler; This means vomit that looks and smells strongly of faeces (poo): This work has been concluded and will be issued to all NHS Pathways sites for the next release in the spring of next year: In addition we have further enhanced our site training package for the management of vomiting in recognition of the difficulties in identifying the nature of vomit remotely via third party telephone triage. am happy to answer any further enquiries from HM Coroner.

Report sections

Investigation and inquest

On the 6th of June 2016 I commenced an investigation into the death of Stuart Gill aged 72 years: The investigation concluded at the end of the Inquest which was concluded on the 24th of August 2016. The conclusion of the Inquest was that Harry Gill died from a heart attack brought on by the effects of vomiting caused by an intermittent blockage in his bowel; His death could probably have been prevented but for the failure to appropriately assess his medical condition.

Circumstances of the death

Harry Gill became unwell and started to vomit on Saturday 28* 2016. He was unable to tolerate food and was trying to take regular sips of water. At 09:S6hrs on Wednesday 1st June 2016 Gill on behalf of her husband contacted NHS 111, The health advisor triaged the call using the vomiting pathway which should have led to a Green response but was incorrectly processed. Arrangements were however made for a clinician to call back some two hours later: clinician should have reached Green 2 response but the triage was incorrectly processed: That call was concluded with advice that should the symptoms get worse or the condition change to ring back NHS 111. At 18.28hrs on Thursday 2nd June 2016 a further call was made to NHS 111 at which time health assistant incorrectly processed the call and although Green response should have been reached instead arrangements were made for a clinical advisor to call back: Three and a half hours later at 21:55hrs. That call was correctly processed and that call concluded with the day Harry day May Mrs The the clinician indicating that an ambulance was going to be arranged: At 22:21hrs on the 20d June 2016 nurse from the Urgent Care Desk then telephoned Mr Gill indicating that the ambulance was not now be being dispatched and that arrangements were going to be made to try and contact and out of hours doctor Mr Gill collapsed and died shortly thereafter. The conclusion reached by who is the 111 Clinical Quality and Nurse Lead for the NHS Service of North West Ambulance Service NHS Trust concluded that of the five calls only one was processed correctly. concluded "we have identified that throughout calls made to NHS 111 and UCD questions stems around vomiting blood/coffee ground vomit were poor. There was not much evidence of supporting information being used even though this is available within the pathways and the Manchester Triage question. Assumptions were made that the callerlpatient understood the presentation of blood in vomit (ranging from bright red to dark brown or black): There was not much probing around the patient vomiting brown fluid or smelling of Since this incident we have requested change to the vomiting and/or nausea pathway via NHS Pathways Issue log, in particular the question stem relating to vomiting blood or faeces: The question stem is misleading to health assistants in regard to having three parts: As yet we have had no response from NHS Pathways regarding this change:

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Report details

Reference: 2016-0323
Date of report: 30 August 2016
Coroner: Michael Singleton
Coroner area: Blackburn, Hyndburn and Ribble Valley

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: 25 Oct 2016 (estimated from the report date).

Sent to

NHS Digital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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