David Ince
PFD Report
Historic (No Identified Response)
Ref: 2014-0497
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
7 Jan 2015
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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
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.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.