Steve Cooke
PFD Report
All Responded
Ref: 2021-0266
All 1 response received
· Deadline: 5 Oct 2021
Response Status
Responses
1 of 1
56-Day Deadline
5 Oct 2021
All responses received
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
Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located:
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied.
(1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner.
The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located
(2) Mr Cooke was very unwell and in need of medical attention:
(i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
Responses
South East Coast Ambulance Service is remedying a deficiency where clear address confirmation procedures from 999 calls were not replicated in the 111 system. They have written two Operational Bulletins: one to ensure 111 call handlers confirm addresses by having the caller state them, and another to improve the process for locating patients when crews cannot find them on scene, involving escalation and thorough record checks. Both bulletins are awaiting internal governance and expected to be in force within 1-2 weeks.
AI summary
View full response
Dear Madam
Steve Cooke deceased
I write in response to the Regulation 28 Prevention of Future Deaths report issued on 8th August 2021 following the inquest into the sad death of Mr Cooke.
I was very sorry to learn of the death of Mr Cooke and I would like to convey my heartfelt condolences to his family and friends.
I have asked the Senior Management Team in charge of our 999 and 111 services to investigate your concerns. They have looked at two issues:
1. Our process for establishing the address to which to send an ambulance
It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.
For 999 calls, the “EOC (Emergency Operations Centre) Call Handling Procedure states in paragraph 2.1:
2.1.1. 999 call answer and incident entry should be followed as per NHSP training.
2.1.2. Any address taken by an EMA that does not match to the EISEC return received from BT must be confirmed to ensure that it is correct. This must be confirmed by the caller giving the address and not the EMA reading it back to them.
This is now being replicated in the 111 service by way of an Operational Bulletin, a copy of which is attached. The Bulletin will be in force as soon as it has gone through internal governance, which should take one to two weeks.
2. Our process upon a patient not being found by crew on scene
A further Operational Bulletin has been written to update and improve our process when crew on scene are not able to locate the patient. I attach a copy. It will be noted that the process involves the escalation of the incident to a team leader who will listen again to the original call to verify the address, search our records for any previous calls from the same telephone number and identify any sources of further information such as next of kin or a careline. If the team leader can locate a family member or careline to call, they must give a full explanation and allow the recipient of the call time to understand what is being said and provide a meaningful response. Checks will also be made of local hospitals and Police.
This bulletin is also making its way through internal governance and is expected to be in force within one to two weeks.
I trust that this provides assurance that the concerns identified in this inquest have been addressed and that if similar circumstances were to occur in the future, our chances of finding the patient are much improved. If I can be of further assistance or can provide any further information, please do not hesitate to contact me.
Steve Cooke deceased
I write in response to the Regulation 28 Prevention of Future Deaths report issued on 8th August 2021 following the inquest into the sad death of Mr Cooke.
I was very sorry to learn of the death of Mr Cooke and I would like to convey my heartfelt condolences to his family and friends.
I have asked the Senior Management Team in charge of our 999 and 111 services to investigate your concerns. They have looked at two issues:
1. Our process for establishing the address to which to send an ambulance
It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.
For 999 calls, the “EOC (Emergency Operations Centre) Call Handling Procedure states in paragraph 2.1:
2.1.1. 999 call answer and incident entry should be followed as per NHSP training.
2.1.2. Any address taken by an EMA that does not match to the EISEC return received from BT must be confirmed to ensure that it is correct. This must be confirmed by the caller giving the address and not the EMA reading it back to them.
This is now being replicated in the 111 service by way of an Operational Bulletin, a copy of which is attached. The Bulletin will be in force as soon as it has gone through internal governance, which should take one to two weeks.
2. Our process upon a patient not being found by crew on scene
A further Operational Bulletin has been written to update and improve our process when crew on scene are not able to locate the patient. I attach a copy. It will be noted that the process involves the escalation of the incident to a team leader who will listen again to the original call to verify the address, search our records for any previous calls from the same telephone number and identify any sources of further information such as next of kin or a careline. If the team leader can locate a family member or careline to call, they must give a full explanation and allow the recipient of the call time to understand what is being said and provide a meaningful response. Checks will also be made of local hospitals and Police.
This bulletin is also making its way through internal governance and is expected to be in force within one to two weeks.
I trust that this provides assurance that the concerns identified in this inquest have been addressed and that if similar circumstances were to occur in the future, our chances of finding the patient are much improved. If I can be of further assistance or can provide any further information, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 22 June 2021 an investigation was commenced into the death of STEVE MARTIN BRIAN COOKE. The investigation concluded at the end of the inquest on 23 July 2021. The conclusion of the inquest was COVID-19 Pneumonia due to COVID-19 Infection - Natural Causes.
Circumstances of the Death
Steven Cooke was found deceased at home on 26th December 2020 by police doing a welfare check due to family concerns of COVID19 Pneumonitis due to COVID-19 infection with a positive test on 23rd December 2020. Steven called an ambulance with extreme shortness of breath and apparent hypoxia on 25th December 2020 and an ambulance was dispatched as a category 2 within 26 minutes. There were communication difficulties, and the ambulance crew was dispatched to the wrong address and Steven was not located.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.