Daniel Maurice McMahon

Dear Mr Walker Daniel Maurice McMahon Regulation 28 Report to Prevent Future Deaths [am writing in reply to the Regulation 28 Report to Prevent Future Deaths dated 21 October 2013, made under paragraph 7, Schedule of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquest into the death of Daniel Maurice McMahon which was heard at North London Coroner's Court between 23 September and 4 October 2013 (inclusive): The report brings to my attention your concerns following the evidence of the court appointed expert in relation to the use of bilateral needle chest decompressions without a valve: As you will be aware, the LAS had available a senior paramedic prepared and able to give evidence on the issue of needle chest decompressions at the inquest but this witness was not called: The LAS have reviewed the matter and that you find the following explanation helpful: Purpose ofneedle chest decompression Needle Chest Decompression forms an important part of the management of chest trauma in the pre hospital environment by paramedic staff: This procedure has the potential to vent pressure from within the thoracic cavity which may occur where the collapses and there is an increasing build up of pressure within the chest: This condition is described as tension pneumothorax This condition can ultimately displace the heart; great vessels and neighbouring causing progressive respiratory and circulatory collapse with catastrophic consequences if left untreated: hope lung lung

In permissive environment such as a hospital, formal drainage of the thoracic cavity would be inserting a chest drain with an underwater seal in situ: In patient who is undertaken by undergoing positive pressure some enhanced hospital teams would undertake an open thaeTgostgmysto llowedrainage of the thoracic cavity under pressure These are not options that are available for use by the majority of paramedic staff and therefore needle chest decompression has formed the mainstay of treatment for addressing potential tension pneumothoraxes Warneri et al. in their 2008 study looking at the safety of needle chest decompression concluded that the use of needle chest decompression appears to be a safe procedure when performed by paramedics in an urban EMS system In this study pre hospital needle chest compression resulted in four cases of unexpected survival Procedure for needle chest decompressions The classic method of needle chest decompression involves the insertion ofa 14 gauge cannula (1.6mm} into the Zud intercostal space just above the third rib in the mid clavicular linechhe needle trocar is then removed and the plastic cannula left in situ and allowed to the chest cavity This technique is described in both the American College of Surgeons Committee Of Trauma Advanced Trauma Life Support Manual? (which is endorsed by the Royal College of Surgeons of England) and in the Pre Hospital Trauma Life Support Manual? fNeither of Vhevse seminal texts On the emergency management oftrauma recommends the use ofa one way valve The American College of Surgeons Committee, Pre Hospital Trauma Life Support Manual actively discourages the use of one way valve citing that there is a negligible chance of inducing an iatrogenic pneumothorax as the port created by the needle chest decompression istvesg much smaller in diameter than the trachea which will act as the preferential air passage It also cites that a makeshift solution of attaching the finger of a medical glove with tip removed as suggested in evidence by your expert Is likely to be fiddly and delv defoiteve Suegeone Sogsensus statement from the Faculty of Pre Hospital Care of the Royal College Surgeons (2007) on the Management of Chest Injuriess makes no mention of the use of one Edinburgh way valves in the section on needle chest decompression. Conclusion Both before and after the inquest this matter has been discussed at some length within the Medical Directorate of the LAS. The Medical Director of the LAS and one of our Senior Paramedics took the opportunity to review our practice Surgeon Commander Leigh Smith, an extensively published author on needle chest decompression and expert on the management of thoracic trauma, and concluded that the current approach of the LAS (and UK ambulance services) is appropriate in respect ofnot using one way valves on needle chest decompressions BSI Michael K Copass, MDZ and Eileen M Bulger; MD' Use of Ncedle Thoracostomy in the Prehospital 'Keir Warner E Environment 2008,Journal of Pre Hospital Emergency Care Vol. 12, No 2 Pages 162-168 American "College Surgeons, Committee on Trauma Advanced Trauma Life Support (2012} Fr Edition College Surgeons_ Committee on Trauma. Pre Hospital Trauma Life Support (2011) 7" Edition American Matthew Revell, Keith Porter, Richard (2007} The pre hospital management of chestinjuries: Caroline Lee, Facalty of Pre-hospital Care ,Royal College of Surgeons of Edinburgh, Emergency Medical Journal 24.220-224. consensus statement doi: 10.1136lemj pre vent with Steyn

hope that you will be assured by the consideration the LAS has given to your report; and by the actions taken to investigate the areas you have raised. My Medical Director; Fionna Moore, and [ would be happy to meet with you to discuss this further ifthat would be useful