Source · Prevention of Future Deaths

Yusuf Abdismad

Ref: 2015-0202 Date: 27 May 2015 Coroner: ME Hassell Area: London Inner (North) Responses identified: 0 / 1 View PDF

Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.

Date 27 May 2015
56-day deadline 22 Jul 2015 est.
Responses identified 0 of 1
Child Death (from 2015)

Coroner's concerns

AI summary
Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.
View full coroner's concerns
In attempting to gain an answer to the question, “Is the patient awake (conscious)?” the emergency medical despatcher first asked “Is Yusuf awake?” When Yusuf’s mother replied “no”, the EMD went on to ask “Is he conscious?”

This seems a confusing way of approaching this very important question. If a person is asleep, then one cannot know if they are conscious without waking them. If the answer to the question “Is he awake?” is “no”, then the most obvious follow up to that would appear to be, “Can you wake him?”

Yusuf’s mother was by now panicking and erroneously replied “yes” to the question of whether Yusuf was conscious, though she had not tried to wake him. The EMD assumed that Yusuf was asleep but rousable, which in fact is unlikely to have been the case.

There were other difficulties with the call, such as the EMD’s failure to recognise that a description of scratches all over might actually refer to a rash, missing the description of pupils no longer visible, and not thinking about the possibility of meningitis. These have, I was told at inquest, been addressed by training, but I remain concerned that such a method of attempting to elicit whether the patient is conscious or unconscious might be used by other EMDs.

Report sections

Investigation and inquest
On 5 January 2015, I commenced an investigation into the death of Yusuf Abdismad, aged 5 years. The investigation concluded at the end of the inquest on 19 May 2015. I made a determination of death by natural causes.
Circumstances of the death
Yusuf died from meningococcal septicaemia. His mother called 999 at 10.42am on 2 January 2015. Following assessment by the emergency medical despatcher, she was advised to call 111. She did so and then at some point during that call, the 111 service called 999 again. By the time the London Ambulance Service arrived, Yusuf was in cardiac arrest.
Copies sent to
Professor Dame Sally Davies, Chief Medical Officer for EnglandAssociation of Ambulance Chief Executives (AACE)National Ambulance Service Medical Directors (NASMeD)NHS England

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Report details

Reference
2015-0202
Date of report
27 May 2015
Coroner
ME Hassell
Coroner area
London Inner (North)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jul 2015 (estimated).

Sent to

London Ambulance Service NHS Trust

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