Source · Prevention of Future Deaths
Samia Shara
Ref: 2014-0548
Date: 19 Dec 2014
Coroner: Fiona Willcox
Area: London Inner (West)
Responses identified: 0 / 2
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There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
Date
19 Dec 2014
56-day deadline
13 Feb 2015 est.
Responses identified
0 of 2
Coroner's concerns
There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
View full coroner's concerns
(1) That long complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance process (2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity_
Report sections
Investigation and inquest
On 1gh June 2013, commenced an investigation into the death of Ms Samia Yasmin Shara aged 1Syears_ The investigation concluded at the end of the inquest on November 2014. The conclusion of the inquest was: Medical Cause of Death (a) Acute Heart Failure (b) Aneurysm of Aortic Sinus and Ruptured Cusp of Aortic Valve. How, when and where and in what circumstances the deceased came by her death: Samia Shara suffered form an undiagnosed congenital heart problem. From around early April 2013 Samia began to experience intermittent shortness of breath and palpitations. She was Seen in general practice and referred to cardiology: However before she was seen she suffered a rare acute complication of her heart problem which led to and caused her death 27th
Conclusion of the Coroner as to the death Natural Causes
Conclusion of the Coroner as to the death Natural Causes
Circumstances of the death
It was clear from the evidence taken during the inquest that she suffered an acute rupture of one of the cusps of her aortic valve causing her to go into crashing heart failure_ Her brother attempting to seek urgent medical advice on her behalf and made calls to 999 and 111_ For various reasons she was not recognised by the call takers to be as unwell as she was until the final call to 999 such that the provision of emergency LAS services were delayed. This delay was not causative in her death on the balance of probabilities, but various incidents occurred, such as the downgrading of the call by a call taker and a failure _to re-triage when the brother called back by a call taker:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
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Report details
- Reference
- 2014-0548
- Date of report
- 19 December 2014
- Coroner
- Fiona Willcox
- Coroner area
- London Inner (West)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Feb 2015 (estimated).
Sent to
- NHS England
- North West Collaborative Clinical Commissioning Group