Source · Prevention of Future Deaths
Steven Jackson
Ref: 2015-0422
Date: 2 Nov 2015
Coroner: Caroline Beasley-Murray
Area: Essex
Responses identified: 0 / 6
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A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Date
2 Nov 2015
56-day deadline
28 Dec 2015 est.
Responses identified
0 of 6
Coroner's concerns
A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
View full coroner's concerns
In the circumstances it is my statutory duty to report lo you: The paramedic who attended at around 10.0Oam gave evidence which indicated that she did not seem to have learned from the events in March 2014. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively: There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as t0 when it is appropriate to convey a patient to hospital.
Report sections
Investigation and inquest
On 29th January 2015 | commenced an investigation into the death of Steven David Jackson. The investigation concluded at the end of the inquest on 27ih October 2015. conclusion of the inquest was a narrative verdict: The cause of death was Ia) Acute Epiglottitis 0 beta haemolytic streptococcus group C as causative organism. Narrative conclusion:- At 6.26am on the 5"6 March 2014, Steven Jackson attended Southend Hospital andwas assessed by an out of hours doctor: At around 1o:ooam ambulance personnel were called to his home and gave him advice. At roopm ambulance personnel again attended after he had collapsed He wvas conveyed to Southend Hospitalwhere he died at 14:26pm There were very serious_ failings in the care Mr Jackson receivedfrom the ambulance staff With appropriate, timely treatment, Mr Jackson would most lieely have survived
Circumstances of the death
Please see box 3 above: The
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. Your RESPONSE You are under a to respond to this report within 56 days of the date of this report, namely by the 15lh January 2016. I, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Copies sent to
Murray duty duty
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Report details
- Reference
- 2015-0422
- Date of report
- 2 November 2015
- Coroner
- Caroline Beasley-Murray
- Coroner area
- Essex
Responses identified
Responses identified
0 of 6
6 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Dec 2015 (estimated).
Sent to
- Bevan Brittan Law Firm
- East of England Ambulance Service NHS Trust
- General Medical Council
- Irwin Mitchell Solicitors
- Southend Hospital Legal Services
- Weightmans Solicitors