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

From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London POC1817376 SWIA 2NS Tel: 020 7210 3000 Mr A Walker Mb-sofs@dhgsigovuk Senior Coroner 82 North London Coroner' s Court 29 Wood Street Barnet London ENS 4BE 2 0 DEC 2013 L V~ll~ Thank you for your letter following the inquest into the death of Daniel Maurice McMahon In your report you state that Mr McMahon died from head injuries after struck by a train Willesden Junction Underground Station. At the time of his death; Mr McMahon had been on leave from Park Royal Hospital while undergoing treatment under the Mental Health Act: I understand the London Ambulance Service will reply to you directly o your concern about their crew s use of a decompression needle without a valve. In your list of concerns you ask that the Department of Health considers: feedback form, where a patient is on leave under S17 of the Mental Health Act; to be completed by those for the patient in the community and the professional staff at the hospital to ensure that any difficulties the patient has whilst on leave are picked up. In relation to the care of mental health patients, we would advise that everyone referred to secondary mental health services should receive an assessment of their mental health needs If it is agreed that the person'$ needs are best met by a secondary mental health service; a care plan should be devised. Services should aim to develop one assessment and care plan that will follow the service user through variety of care settings to ensure that correct and necessary information goes with them_ Cioz 030 7343234 being leaving using caring

In reviewing a care plan as part of discharge planning from hospital or other residential settings, appropriate liaison with mental health services in the community is essential The period around discharge is a time of elevated risk; and particularly of self-harm: This underlines the need for thorough review and assessment prior to discharge and effective follow-up and support after discharge. Mental health trusts should ensure that individuals with higher support needs are identified and appropriately supported. All care plans must include explicit crisis and contingency plans: This includes arrangements so that the service user or their carer can contact the right person if need to at any time with clear details of who is responsible for addressing elements of care and support. We are currently reviewing the advice in the "Code of Practice Mental Health Act 1983". This includes reviewing the chapter on leave of absence under section 17 of the Mental Health Act 1983 and the references to care planning: The experience of this case will be used to assist that review. 1 that this response is helpful and [ am grateful to you for bringing the circumstances of Mr McMahon'$ death to my attention Jins 7 JEREMY HUNT they - hope