Source · Prevention of Future Deaths
Stephen Bedford
Ref: 2014-0159
Date: 9 Apr 2014
Coroner: David Morris
Area: Cambridgeshire (South & West)
Responses identified: 0 / 3
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Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Date
9 Apr 2014
56-day deadline
4 Jun 2014
Responses identified
0 of 3
Coroner's concerns
Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
View full coroner's concerns
_ (1) Whether the Trust's Emergency Care Assistants (ECA) and Emergency Medical Technicians EMTLare assessed at intervals_to ensure compliance with Basic Life and and Artery hrs _ day:
Support(BLS) and Immediate Life Support (ILS) standards and scope of practice_ (2JWhether the Trust's paramedics or otherwise only those with Advanced Life Support (ALS) training should be mandated to attend all Code Red ambulance transfers of patients diagnosed with acute coronary syndrome(ACS) (3)Whether at the point of community referral (patient's home, GP surgery or elsewhere) the referring individual or team are made aware by the ambulance crew of the scope of their training(i.e. BLS, ILS or ALS) to ensure an informed and optimal decision to transfer is taken.
4.Whether the Trusts paramedics, or only those with current ALS training should be mandated to attend all transfers post-activation of the Trusts Primary Percutaneous Coronary Intervention protocol EoE PPCI).as stipulated in that protocol:
5. Whether the Trust's ECA and EMT crews should be made familiar with and instructed to adhere to the EoE PPCI protocol following any PPCI referral from the community or hospital and whether practical guidance in support of the protocol should be given on the lines suggested in the appendix attached.
6. Whether ECA's and EMT's should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether should attend the Trust's ILS Courses
7. Whether contact with and continuing dialogue with relatives should the subject of specific guidance once next of kin details have been established,
Support(BLS) and Immediate Life Support (ILS) standards and scope of practice_ (2JWhether the Trust's paramedics or otherwise only those with Advanced Life Support (ALS) training should be mandated to attend all Code Red ambulance transfers of patients diagnosed with acute coronary syndrome(ACS) (3)Whether at the point of community referral (patient's home, GP surgery or elsewhere) the referring individual or team are made aware by the ambulance crew of the scope of their training(i.e. BLS, ILS or ALS) to ensure an informed and optimal decision to transfer is taken.
4.Whether the Trusts paramedics, or only those with current ALS training should be mandated to attend all transfers post-activation of the Trusts Primary Percutaneous Coronary Intervention protocol EoE PPCI).as stipulated in that protocol:
5. Whether the Trust's ECA and EMT crews should be made familiar with and instructed to adhere to the EoE PPCI protocol following any PPCI referral from the community or hospital and whether practical guidance in support of the protocol should be given on the lines suggested in the appendix attached.
6. Whether ECA's and EMT's should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether should attend the Trust's ILS Courses
7. Whether contact with and continuing dialogue with relatives should the subject of specific guidance once next of kin details have been established,
Report sections
Investigation and inquest
On 2 August 2012 commenced an investigation into the death of Stephen Anthony BEDFORD, aged 33. The investigation concluded at the end of the Inquest on 11 July 2013. The Conclusion of the inquest; handed down on 31 October 2013, was that: Stephen Anthony Bedford died from a Natural Cause namely: 1a Acute Myocardial Ischaemia 1b Coronary Thrombosis The outcome might have been different had he been transferred in a more timely manner to the nearby Specialist Coronary Intervention Centre
Circumstances of the death
Stephen Bedford aged 33 years had a past medical history of Type Diabetes Mellitus and hypercholesterolemia: On 31.7.12 he experienced central chest pain whilst at a gym. En route home he attended Eaton Socon Health Centre where he collapsed at about 1600 An ambulance was called and he was conveyed to Bedford Hospital A&E where he was diagnosed with an ST elevation myocardial infarction: The same ambulance crew then conveyed him to Papworth Hospital via PPCI arriving at 1805 hrs with a history that he had arrested en route. Despite intervention death was confirmed at 1940 hrs the same
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and the East of England Ambulance Service NHS Trust have the power to take such action;
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Report details
- Reference
- 2014-0159
- Date of report
- 9 April 2014
- Coroner
- David Morris
- Coroner area
- Cambridgeshire (South & West)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Jun 2014.
Sent to
- East of England Ambulance NHS Trust
- Messrs Hempsons
- Messrs Stewarts Law LLP