LAS Ref: 15641

His Majesty's Coroner Inner North London Coroners Court Inquest touching the death of Ms Ivy May Dixon

STATEMENT OF

LAS Ref: 15641 I will say as follows: Background
1. My name is ; I am the Senior Clinical Lead for Legal Services for the London Ambulance Service NHS Trust. I have responsibility of clinical oversight for cases involving legal services. My main responsibilities include reviewing inquests and clinical claims, representation of the Trust, undertaking incident investigations (including patient safety investigations), Learning from Death reviews via Structured Judgement Reviews and providing clinical opinions. I remain in active clinical practice and regularly undertake shifts as a Paramedic and as Senior Clinical advisor for the Trust.

2. My full qualifications are: Bachelor of Science Degree (Honours) in Paramedic Science. I have been a Paramedic registered with the Health and Care Professions Council (PA34712) since 2012 and am a member of the College of Paramedics. Prior to undertaking this role, I was one of Trusts Quality, Governance and Assurance Managers responsible for North Central Sector as well as a Staff Officer to the Deputy Director of Operations

Purpose of The Report and Materials Examined:
1. Thank you for requesting this clinical statement covering a clinical review of the incident involving Mrs Ivy May Dixon attended to by the London Ambulance Service (LAS) on the 06 October 2024. This statement will provide an overview of clinical care provided to Mrs Dixon,

LAS Ref: 15641

and will seek to address the following concern raised by HM Coroner:

“Assistant Coroner Potter heard evidence from a registered nurse at Acorn Lodge Care Home (the current Home Manager) that because choking is regarded as a reversible cause, they consider that CPR should have been provided to Mrs Dixon on 6 October 2024.”

2. I have had no direct involvement with the care or treatment of Ms Ivy May Dixon.

3. I have reviewed the following documents as part of my review:  Electronic call log for CAD 3998 on the 06 October 2024.  Audio tape for CAD 3998 on the 06 October 2024.  Electronic Patient Care Record (ePCR), case reference number M1XV16390D6E completed on the 06 October 2024 by the attending clinician.  Signed statement of Paramedic , dated 07 January 2025.  Signed addendum statement of Paramedic , dated 13 February 2025.  Post Mortem Report dated 07 January 2025, consultant pathologist .

Timeline of London Ambulance Service Involvement on Scene For noting: The times provided can be sourced from different references, the times detailed from the control room records are derived from the control room computer system and this is synchronised with an electronic clock for accuracy and recorded on the call log. The defibrillator has an electronic clock, which is checked on service, and when connected to a computer but can show a slight difference to the times on the control room system. In terms of the times an ambulance clinician records on the clinical record this may be from a personal watch or potentially an estimate of the time. Clinical Record timings are often completed following patient handover and require manual manipulation of the automatic clock. This can often lead to discrepancies in relation to the timings on the clinical record.

Time Time Elapsed Detail 06 October 2024 18:15 (hours: minutes) 00:00 (hours: minutes) A 999 call (CAD 3998) was received and answered immediately. The patient was reported to be breathing and conscious. The call was for a 96-year-old female with the problem description provided as “Choking”.

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The call was triaged by Medical Priority Dispatch System (MPDS)1 and received the determinant “(11D1F) - Abnormal breathing (PARTIAL obstruction)”. This received a pre-determined category 1 response profile2. 18:18 00:03 A Fast Response Unit (FRU), call sign G350, staffed by a Paramedic was dispatched to the incident location.

A Double Crewed Ambulance (DCA), call sign K335, staffed by a Newly Qualified Paramedic (NQP) and a Trainee Assistant Ambulance Practitioner (TAAP) was dispatched to the incident location. 18:21 00:06 FRU, call sign G350, arrived on scene at the incident location. Following arrival the clinician was met by care home staff and led to a bedroom where Mrs Dixon was located in a hospital bed.

An initial assessment was undertaken, which identified that Ms Dixon was unconscious, not breathing and had no palpable pulse indicating she was critically unwell and in confirmed cardiac arrest.

The following history was provided: It was recorded, “Care home staff were attempting to feed the pt [patient] this evening, noted the pt was only eating liquids and was not for solid food. As staff were attempting to feed pt state [sic] that she became unresponsive and made “gasping” sounds therefore were unable to give her any food. Staff were concerned so called 999. As staff were unable to actually feed pt no liquids were given to pt – not a reversible cause. No evidence of vomit or liquids in the airway”. 18:29 00:14 G350 contacted the Emergency Operations Centre (EOC) and advised that Ms Dixon was in cardiac arrest and that no further resources were required. K335 was stood down from the incident.

The following note was recorded on the log: ‘Pat [patient] deceased, DNJAR [sic – DNACPR] in place, NFRR [no further resources required]’ 18:31 00:16 A set of observations was recorded as follows:

• Respiratory Rate – 0 breaths per minute
• Heart Rate – 0 beats per minute
• Pupils – 7mm, both fixed (indicating that Mrs Dixons pupils were dilated and not reactive to light)
• Glasgow Coma Scale – 3/15 (indicating Mrs Dixon was unconscious)

A cardiac rhythm analysis was undertaken which identified that Ms Dixon was asystolic3

1 Medical Priority Dispatch System is a national call taking system which assists call handlers to triage calls and establish a response profile. 2 Category 1 calls as a cohort of calls have a mean response target of 7 minutes and a 90th centile response time target of 15 minutes. This is a commissioning target for the total number of calls of a specific category and is not assigned to an individual call. Even where an ambulance service is achieving its 90th centile target, there will still be response times for individual calls which fall outside of the target. 3 Asystole represents total cessation of electrical and mechanical activity of the heart.

LAS Ref: 15641

Verification of the fact of death was completed citing a DNCPR was in place and confirmed the patient had no pulse or respirations. All required examinations were completed.

Call Handling and Dispatch
4. It is outside the scope of this review to comment on the handling and accuracy of the 999 call but I note the call was triaged as category 1 which is the highest response profile. With the current information available this appears appropriate.

5. It is noted that the overall response time to the call was 6 minutes.

6. On review an appropriate number and skill of resources were dispatched to the call. The double crewed ambulance was cancelled by the attending clinician following their arrival.

Summary of Clinical Care

7. I note that Ms Dixon was at the time of her death a 96 year-old-female with a history of dementia and hypertension (high blood pressure). The clinical record suggests that she was bed bound and was noted to be on a liquid diet suggesting she had reduced mobility and a level of frailty and likely a poor swallow.

8. I note a provisional cause of death has been provided as:

1a. Asphyxia 1b. Choking on Food II. Essential hypertension and Type II diabetes mellitus

9. On review of the post mortem I note a key finding indicated that “the tracheo-bronchial tree was obstructed by greenish/grey pureed food”. To assist with understanding, Ms Dixon’s breathing pipe (trachea) was obstructed with pureed food to the point at which the trachea divides into the left and right lung (bronchus). This is outlined in the diagram below.

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Management of Ms Dixon
10. On arrival of the clinician, they were promptly shown to the location of Ms Dixon. She was noted to be semi-recumbent in a hospital bed and in receipt of oxygen via a high flow mask. No further treatment was being provided by the care home staff at the time of their arrival. There was no ongoing resuscitation.

11. The clinician undertook a primary survey. This identified that Ms Dixon was unresponsive, was not breathing and had no detectable pulse (indicating there was no palpable heart beat). This indicated that Ms Dixon was in a confirmed cardiac arrest. The clinician confirmed no bystander CPR had been provided prior to their arrival.

12. The clinician ascertained that Ms Dixon had become unresponsive as staff at the home were attempting to feed her, she was noted to have made gasping noises and 999 was contacted. The staff informed the clinician that no food had been provided to Ms Dixon prior their arrival on scene and further that Ms Dixon had a do not attempt cardiopulmonary resuscitation (DNACPR) order in place.

13. The clinician appropriately undertook a visual inspection of Ms Dixons airway from her semi- recumbent position in the hospital bed. This would likely have enabled visualisation to the back of the mouth (oropharynx). On inspection there was no noted food detritus to indicate that Ms Dixon’s cause of arrest was choking. In consideration of this along with the fact the staff had advised they had not provide Ms Dixon with any food in conjunction of the

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knowledge that Ms Dixon has a DNACPR in place, the clinician made the decision that Ms Dixon was unlikely to be choking and as a result, undertook verification of the fact of death at 18:31 considering the cause of the arrest was likely in line with the DNCPR. No further treatment was provided.

14. Clinical guidelines in relation to presentations of choking when a valid DNACPR is in place are presented within JRCALC (Joint Royal College Ambulance Liaison Committee) guidelines under ‘Termination of Resuscitation and Verification of Death in Adults’. This is included below:

JRCALC, (2022), ‘Termination of Resuscitation and Verification of Death in Adults’
15. Choking is considered a reversible cause, and therefore consideration should be made to clinical treatment. Where a clinician is presented with an unconscious patient as a result of choking, expectations are that LAS clinicians consider national JRCALC guidance which is provided below:

16. In this case, the clinician appropriately undertook a visual inspection of the airway, however, one could considered a further examination with a laryngoscope4. Had this occurred it would

4 A laryngoscope is an instrument consisting of a blade and handle which is inserted into the patients mouth to enable visualisation of the of the larynx and vocal cords. It allows further review of a patient’s airway.

LAS Ref: 15641

have enabled further visualisation of the patient’s upper airway to the opening of the larynx (up to the vocal cords). A diagram is provided below to assist with visualisation of this.

17. Whilst this is considered, it is important to note that the use of suction prior to the arrival of the clinician may have removed any blockage or evidence of detritus above the larynx. Further given the description of the blockage, it would not have been possible to visualise any blockage below the vocal cords. In consideration of this there would have been no blockage which the clinician could either have identified or removed.

18. Where a patient has aspirated (where food, liquid or foreign substances) are accidently inhaled into the trachea and lungs (beyond the vocal cords), there is limited treatment options available to the clinicians and where this has occurred, there is limited success in removal.

19. Once the airway has been examined and any obstruction removed, guidance advises that basic life support should be initiated. One is minded to consider that on arrival of the clinician Ms Dixon was in confirmed cardiac arrest. On review of the statements and clinical record provided, there had been no provision of cardio pulmonary resuscitation prior to the arrival of the clinician and the time at which she deteriorated into cardiac arrest was unknown.

20. On review of the information provided, and in consideration of Ms Dixon’s previous medical history and evident frailty, once must consider that whilst basic life support could have been initiated it would be very unlikely to have resulted in a successful outcome. There is a careful balance between ensuring a patient receives medical care and that any care provided will have a meaningful outcome.

LAS Ref: 15641

21. Where a patient has deteriorated into cardiac arrest as a result of choking, the prognosis of a patient is extremely poor. Current data is suggestive of a less than 6% survival rate When you consider this figure in the context of a patient with marked frailty and no immediate option to clear the airway any chance of survival would have been minimal at the most.

22. In consideration of the information provided on the 999 call, the caller advised that Ms Dixon had started choking following being fed, that her oxygen saturations were deteriorating, they had used suction, she had shallow breathing and they had applied oxygen. On review, It is not clear why the information provided to the 999 call handler differed to the information provided to the clinician on scene. Had the clinician been informed of the circumstances outlined on the 999 call, it is not unreasonable to consider that the clinician would have considered the cause of the arrest to be choking but on balance I am not of the view that with no obvious obstruction of the airway this would have changed either any intervention or outcome.

23. The completed clinical record, subsequent clinical statements and discussions with the clinician indicate that at the time of the attendance to Ms Dixon they were aware of the guidance. Whilst this is recognised, there were indications of an obstruction and whilst in my opinion their care was not wholly unreasonable, they have been receptive to feedback. Their verbalised insight and reflection of the attendance to Ms Dixon has been commendable.

I would like to take this opportunity to extend my deepest sympathies to the family and friends of Mrs Dixon and would like to apologise for any distress caused by this statement.

STATEMENT OF TRUTH I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.

LAS Ref: 15641

DECLARATION I, declare that: I understand that my duty included in my providing written reports and giving evidence is to help the court on the matters within my expertise. I confirm that I have complied with that duty and will continue to comply with it. This report is addressed to the court. I understand that this duty overrides any obligation to London Ambulance Service NHS Trust. Name: Signature: Date: 24th February 2025

Confidential

IN THE PROPOSED MATTER OF AN INQUEST INTO THE DEATH OF

Ivy May Dixon

_______________________

WITNESS STATEMENT OF

________________________

________________________________________________________________

I, WILL SAY as follows:

1. I am a Band 6 paramedic and I have been working for the London Ambulance Service (LAS) since the 1st of July 2021. My station/base is Cody Road Ambulance Station.
2. I have been requested to complete a witness statement by the Coroner. It has been requested that I cover when I arrived on scene to when the deceased was left in the care of others.
3. I have referred to the ePCR to prepare this statement. No other documents or references have been used.
4. On the 6th of October 2024 I was working under the call sign of G350 out of Homerton Ambulance Station. At 18:18 I was dispatched to CAD 3998, it was given as category 1 call with the chief complaint of choking with abnormal breathing.
5. I arrived on scene at 18:21 and was met by care home staff outside. I was led inside and into the patients bedroom, the patient was in a hospital bed in a semi-recumbent position with high flow oxygen mask on the patients face.
6. In the room was two care home staff and a nurse.
7. When I assessed the patient they were not breathing and did not have a pulse. I asked the staff what had happened and they had stated that they were attempting to feed the patient thick liquids when she became unresponsive and made a gasping sound.

8. I clarified with the staff that they were unable to feed the patient any food. No food was given to patient.
9. Staff stated that is when they called 999.
10. Staff on scene including the registered nurse stated that no CPR was commenced prior to LAS arrival.
11. The nurse who was present stated that the patient had a DNAR (do not attempt resuscitation), she presented the valid DNAR to myself.
12. I assessed the patient’s airway and no food, liquid or secretions present, confirmed with staff that they were unable to feed patient as she was unconscious.
13. To assess the patient’s airway I opened her mouth and visually inspected the airway which was clear and no evidence of food was found.
14. There is no official mention of the processes/procedures for airway management in patients who have suspected choking in the LAS Airway Management Policy OP077.
15. In our JRCALC (Joint Royal Colleges Ambulance Liaison Committee) guidelines it advises that for an unconscious patient with a severe airway obstruction you begin CPR. To manage the airway you open the mouth and look for any obvious obstruction. Then attempt to visualise the vocal cords with a laryngoscope. If an obstruction is seen and it can be grasped easily, make an attempt to remove it with forceps, or suction.
16. As the staff on scene specifically stated to myself that they were unable to feed the patient, there was a low clinical suspicion of choking so CPR was not commenced.
17. With LAS guidance if the cause of cardiac arrest was choking it is deemed as a reversible cause and BLS should be started even if the patient has a DNACPR.
18. As the patient was not breathing, did not have a pulse and had a valid DNACPR no BLS (basic life support) was attempted.
19. I updated EOC (emergency operational centre) stating that there was no further resources required.
20. I confirmed ROLE (recognition of life extinct) at 18:31.
21. I then left the patient in the care of both the nurse and two further care home staff in the patient’s bedroom and completed my paperwork in my vehicle.

Statement of Truth

The contents of this statement are true to the best of my knowledge and belief.

Signed: ………………………….……..

Dated: ....13/02/2025..........................................................................