Source · Prevention of Future Deaths

Thomas Collins

Ref: 2015-0469 Date: 25 Nov 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 2 / 2 View PDF

The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.

Date 25 Nov 2015

56-day deadline 20 Jan 2016

Responses identified 2 of 2

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.

View full coroner's concerns

The attending paramedic lacked the confidence to make a clinical decision, which accept can happenbut he then contacted the Out of To the 24th

Responses

2 respondents

North West Ambulance Service NHS Trust NHS / Health Body

13 Jan 2016 PDF

Noted

The North West Ambulance Service describes its existing 'Paramedic Pathfinder' algorithm and referral process to Acute Visiting Services, asserting it is a considered and auditable system. (AI summary)

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Dear HM Senior Coroner Pollard, Re: Inquest into the untimely death of Thomas Anthony Collins Date& Time of hearing: Wednesday 18th November 2015 at 10am Location: Stockport Coroners Court Matter: PFD Regulation 28 Report Thank you for your letter dated 25 November 2015 which encloses a copy of the Regulation 28 report issued against NWAS, pursuant to section 7 (1) (c) ofthe Coroners and Justice Act 2009. note your specific concern centres around the following: 'The attending paramedic lacked the confidence to make a clinical decision, which accept can happen, but then he contacted the Out of Hours doctors who had no knowledge of the patient rather than his own GP practice. When, in what circumstances, should a paramedic seek the advice of a doctor who is not in attendance, as to whether the patient is to be taken to hospital? (NWASY' confirm that NWAS Paramedics perform a clinical assessment of the patient and then apply a clinical algorithm called 'Paramedic Pathfinder' . The algorithm is used by a Paramedic to ensure the sickest patients receive rapid care and transport to the Emergency Department an evidence-based process The algorithm allows the Paramedic to identify patients who would benefit from clinical assessment and care at home before a decision is made to transport to hospital. The algorithm identifies a cohort of patients clinically safe to wait up to 2 hours for a further, more bespoke clinical assessment (ref : Emerg Med J published online October 7, 2013 Clinical Navigation For Beginners: clinical utility and safety of the Paramedic Pathfinder) NWAS has agreements with thirty Commissioning Groups (CCGs) in the North West to refer this group of patients to a specific 'Acute Visiting Service' (AVS), usually organised by GP Out of Hours services. Headquarters: Ladybridge Hall. 399 Chorley New Road_ Bollon. BL 5DD Chair: Ms W Deliverilc; the tich: care. ~l Ine rixhht Ihe rigtit Facl Chlel Executive: Mr 8 Willlams using Dignan 1,7 ,

These services are easily available to NWAS staff in a timely manner (within 15 minutes): There is a Memorandum of Understanding that these services are aware of the skill set of our staff and that patients 999 have a higher 'prior probability' of being significantly unwell than the usual General Practice patient: A minimum "data of information is required from the Paramedic in order to support a decision about transport to hospital: The referral calls are recorded for audit purposes: We know from experience that calling the patient $ own GP results in variable response, both in terms of timeliness of clinical advice and how consistent that advice is. The Out of Hours GP will contact the patients own GP for follow up care and advice ifit is established that the patient does not need a more urgent intervention: The GP is informed that the Acute Visiting Service has been involved within 24 hours of the contact: hope this letter provides assurance that we have a considered, clinically evidence based and auditable system for safe structured hand-over of patients to their local health care system that has been developed with Commissioners and local health care providers; Ifyou do have ay further concerns or questions please feel free to contact me. Kind regards Head of Legal Services calling set"

Haughton Thornley Medical Centres Other

PDF

Action Planned

The practice will ensure that when accidents happen with Thomas and Amy Senior and Tony Swales, they will obtain more information surrounding the circumstances of the fall and will clearly record their findings. In cases of suspected stroke the hospital will be contacted. (AI summary)

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Report sections

Investigation and inquest

On 21st July 2015 commenced an investigation into the death of Thomas Anthony Collins dob gth October 1970. The investigation concluded on the 18th November 2015 and the conclusion was one of Accidental Death: The medical cause of death was 1a Sepsis and Multi-organ failure 1b Pneumonia and Adult Respiratory Distress Syndrome 1c Fractured Ribs 11 Alcoholic Liver Disease

Circumstances of the death

Mr Collins lived in a Care Home as a result of his ill-health due to drinking excess alcohol for many years. In the home, on 22nd June 2015, he fell and damaged his chest: He was attended by his own GP on the June 2015, who, despite the obvious serious and intense pain felt by the deceased, declined to admit him to hospital: A paramedic attended him on the 22nd June 2015,and this paramedic felt it necessary to obtain an opinion from a doctor; S0 he contacted the Out of Hours Service even though the GP surgery where the deceased was registered was in fact open. The OOH GP then purported to give informed advice to the paramedic, even though he could not examine the patient: It was decided not to take the patient to hospital. The cardio-thoracic surgeon gave evidence to me that if the patient had been taken to hospital on the 22' when the injury occurred, "he would still be around today" On the 25th June he was eventually taken to Tameside Hospital, and on the 26th he was transferred to the Tertiary Unit for chest medicine, was then in the ITU until he transferred back to Tameside on the 6th July 2015,and he died there on the 15th July:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have power to take such action,

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Report details

Reference: 2015-0469
Date of report: 25 November 2015
Coroner: John Pollard
Coroner area: Manchester (South)

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Jan 2016.

Sent to

Haughton Thornley Medical Centres

North West Ambulance Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.