Source · Prevention of Future Deaths

Patricia Mercieca

Ref: 2016-0260 Date: 19 Jul 2016 Coroner: Dr Fiona Wilcox Area: London Inner (West) Responses identified: 1 / 1 View PDF

Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.

Date 19 Jul 2016

56-day deadline 13 Sep 2016 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ (1) That the call handlers need to be refresher trained in relation to contacting resident managers for Westminster residents following a medical emergency call: (2) That wherever there is a person contacting them in an emergency where there is a manager; that manager should be contacted whatever authority covers the person contacting the call handler.

(3) That if a call handler is directed by emergency services such as the LAS, or other relevant professionals such as a doctor to obtain further information or reassess then should do so and pass any information so gained back to the agency or professional that requested it: (4) That call handlers be trained such that if get no response when contacting a person who has contacted them and that person is a user of the emergency call system, then immediate concerns should be raised with the appropriate agencies for example the_LAS and resident scheme manger

Responses

1 respondent

London Ambulance Service NHS / Health Body

2 Dec 2016 PDF

Noted

The London Ambulance Service states that based on their understanding of the call records, no changes to the questions asked of 999 callers would have enabled them to triage the call differently, unless they had been informed that contact with the patient had been lost. (AI summary)

View full response

London Ambulance Service NHS NHS Trust Executive Office Headquarters 220 Waterloo Road London SEI 8SD Tel: 020 7783 2000 Director Response and Customer Operations Tunstall Healthcare (UK) Ltd Ascot House Malton Way Adwicke le Street Doncaster DN6 7FE Our ref INQ/11406/15 2 December 2016 Response to Regulation 28 Report relating to Patricia Mercieca deceased apologise for the delay in writing after receiving a copy of your letter dated 30 August 2016 from to HM Senior Coroner on 27 September 2016, arising from the Regulation 28 Report issued by Dr Wilcox after the inquest into the death of Patricia Mercieca. Whilst supporting whole heartedly your wish to ensure that appropriate lessons are learned which may prevent future deaths should like to respond to your invitation to the Coroner to consider: "What steps could be taken by an emergency service when triaging calls where it is informed that a third party requesting an emergency response is not in attendance with the casualty. Tunstall feel that the London Ambulance Service 'script' failed to fully recognise this situation in the present case resulted in additional confusion between the respective call operators. My understanding of the London Ambulance Service NHS Trust'$ call records concerning the call made on behalf of Ms Mercieca was that single call was made, it was known and recorded that it was a third party caller who was not with the patient: Regrettably when contact with Ms Mercieca was lost and Tunstall were unable to make contact they did not update the LAS of that situation. Had Tunstall informed the LAS that communication had been lost and Ms Mercieca was 71o7020/ 6 25 again

not responding; am advised by Head of Quality Assurance Control Services, who gave evidence at Ms Mercieca's inquest, that the call would have been upgraded to a Category A or Red call with a target response of 8 minutes for 75% Red calls As explained in her evidence while the call was being held awaiting an available response it was reviewed by an LAS clinician with the intention ofmaking a clinical assessment by telephone, but without a contact telephone number the clinician upgraded the priority ofthe call from C2 to C1_ am satisfied that there are no changes to the questions asked of 999 callers that would have enabled the LAS to triage the call differently aside from the update that contact with the patient had been lost and she was not responding: am hopeful however, that the measures taken by Tunstall to address the Coroner's concerns will help prevent future deaths. If you would find it helpful to meet and discuss further with and our Deputy Director of Operations, Control Services please let my Jknow so that the arrangements can be made

Report sections

Investigation and inquest

On the 17h July 2015 an investigation was opened touching the death of Patricia Mercieca; who died aged 60 years on the 14 2015 at Flat 34, Charlwood House, Vauxhall Bridge Road, London: SWIV 2SY. inquest was concluded on the 12th July 2016 at Westminster Coroner's Court: The following findings and determinations were made: The medical cause of death was recorded as: 1(a) Chronic Obstructive Pulmonary Disease and Asthma and Methadone Intoxication. How, when and where and in what circumstances the deceased came by her death: Patricia had a long standing history of drug dependence, severe COPD and asthma and was resident in assisted living accommodation. On the 14/7/2015 she pulled the emergency cord at her address at approximately 21.00 and informed the call handler that she could not breathe. arrested shortly after this such that on the arrival of the LAS at approximately 22:15 she was found to be deceased. Conclusion of the Coroner as to the death: Natural Causes and Dependence

Circumstances of the death

Evidence taken at the inquest was that the call handler called the LAS to request an ambulance however did not give correct information to the LAS such that the call could be correctly prioritised. The LAS clearly on two occasions advised the call handler to recheck whether Ms Mercieca could talk without becoming short of breath which if she could not would have upgraded the call priority: The call handler did not do this. In fact when the call handler re contacted Ms Mercieca to let her know an ambulance was on July The She Drug the way, she did not respond to him at all. He did not pass this information onto the LAS and also did not; in contravention of the agreement between Tunstall Response and Westminster; contact the manager of the supported housing in which Ms Mercieca was resident: The evidence was that if he had so done, that manager was at home in the same accommodation block and would have immediately attended Ms Mercieca' s flat to give any appropriate assistance On consideration of the evidence since it was not known when Ms Mercieca arrested, it could not be said on the balance of probabilities that had the call been appropriately handled she would have survived and so the failures could not be said to be causative in her death The evidence was that the call handler was acting in line with company procedures when he did not follow up with Ms Mercieca as requested by the LAS_ Further not all authorities with which Tunstall are contracted to respond to handle calls require that their managers are contacted when a resident contacts Tunstall in an emergency: understand that Tunstall handle approximately two million calls per annum, of which approximately 10% are medical emergencies. Most authorities with which they contract do not have resident managers in their supported housing schemes. The evidence was also that the medical history of Ms Mercieca was not recorded on the computer screen available to the call handler and so could not be passed to the LAS. This information would have also upgraded the call. understand that audit procedures are in place to address this matter.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIQR your organisation] have the power to take such actionIt is for each addressee they they to identify the concerns relevant to their own areas of responsibility.

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Shared signals

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Report details

Reference: 2016-0260
Date of report: 19 July 2016
Coroner: Dr Fiona Wilcox
Coroner area: London Inner (West)

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 Sep 2016 (estimated).

Sent to

Tunstall Response

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.