Source · Prevention of Future Deaths
David Ince
Ref: 2014-0497
Date: 12 Nov 2014
Coroner: Sian Jones
Area: Preston & West Lancashire
Responses identified: 0 / 1
View PDF
Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.
Date
12 Nov 2014
56-day deadline
7 Jan 2015
Responses identified
0 of 1
Coroner's concerns
Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.
View full coroner's concerns
In circumstances it is my statutory duty to report to you: (UJIn_the course of the Inquest_hearing_it became apparent that the_NWAS electronic the record referred to an ECG having been carried out on Mr Ince by the ambulance Staff at 11.35pm, prior to his first admission to A&E However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personnel on arrival at RPH, and no ECG trace was handed over or seen by A&E staff; (2) It was the evidence of the Middle Grade doctor in Emergency Medicine: who had subsequently assessed and treated Mr Ince in the A&E department; that NWAS stalf_ Often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department
Report sections
Investigation and inquest
On 27 June 2014 commenced an investigation into the death of David Anthony Ince_ The investigation concluded at the end of the inquest on 23rd October 2014. The conclusion of the inquest was medical cause of death 1(a) Hypoxic-ischaemic encephalopathy 1(b) Cardiac arrest (resuscitated) I(c) Ischaemic heart disease and narrativve conclusion David Anthony Ince was admitted by ambulance to Royal Preston Hospital at 00.06 on 26/06/14 having suffered a collapse at home: The clinical history and investigations suggested that the event was a syncopal episode of the sort Mr ince had been suffering for some months: He was discharged in the early hours but shortly alter having arrived home; he suffered a cardiac arrest which was unsurvivable despite readmission to hospital
Circumstances of the death
See narrative conclusion above.
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.
Similar PFD reports
Related inquiry recommendations
Southport Inquiry
Healthcare trust risk information visibility
COVID-19 Inquiry
Data Systems for High-Risk Individuals
Muckamore Abbey Inquiry
Full staff access to care plans
Muckamore Abbey Inquiry
Easy Read documents
Muckamore Abbey Inquiry
Clear records and disclosure policies
Muckamore Abbey Inquiry
Accessible financial records
Muckamore Abbey Inquiry
Six-monthly financial accounts to families
Muckamore Abbey Inquiry
Named person approval for transfers
Fuller Inquiry
Ambulance data on conveying deceased
Infected Blood Inquiry
Patient Records Audit
Report details
- Reference
- 2014-0497
- Date of report
- 12 November 2014
- Coroner
- Sian Jones
- Coroner area
- Preston & West Lancashire
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: 7 Jan 2015.
Sent to
- North West Ambulance Service NHS Trust