Amanda Gainford
PFD Report
Partially Responded
Ref: 2024-0571
Coroner's Concerns (AI summary)
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.
View full coroner's concerns
During the inquest the court heard evidence from the North West Ambulance Service (NWAS) witness who confirmed that call handlers for the service are not medically trained but receive basic medical training. The system used nationally to categorise calls is reliant upon questions asked and information which is input by the call handler to achieve a categorisation of a call. In this case, there was no evidence the call categorisation was incorrect, however, an ambulance was called on 3 occasions due to Amanda's condition, on the last occasion that call was made by a Doctor on the scene providing care for Amanda, who was of the opinion that he was unable to keep the patient stable due to low blood pressure over a prolonged period. The NWAS witness gave evidence to the court that had the Doctor disagreed with the category 2 classification of the call or sought to escalate his clinical concerns regarding a patient, that he had the ability to challenge that and to request a review by a clinician available to NWAS. The Doctor was unaware that he had the ability to challenge the call handler categorisation and to seek a review by a clinician at NWAS, at which point the nature and seriousness of Amanda's condition could have been further reviewed and clearly understood. At a further course attended subsequently by the Doctor he advised that of 50 Doctors in attendance, only 1 was aware of the ability to escalate concerns regarding a patient and the categorisation of a 999 call to the Ambulance service and subsequent response time. It appears that this is an important fact unknown by many clinicians which would enable a clinician to clinician review of a critical patient and the use and dispatch of ambulance resources to prevent the loss of life in critical cases which are not automatically categorised at the highest level of response.
Responses
Noted
NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group. (AI summary)
NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Amanda Jane Gainford who died on 4 November 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 October 2024 concerning the death of Amanda Jane Gainford on 4 November 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Amanda’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Amanda’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Amanda’s family or friends. I realise that responses to Coroner’s Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them. Your Report raised the concern that many healthcare professionals (HCPs) were unaware of their ability to challenge ambulance call hander categorisation and seek a review by a clinician. NHS England has published the National Framework for healthcare professional ambulance responses, which was last updated in March 2021. The Framework is intended for patients who require an ambulance response in a community setting following clinical assessment by a HCP. HCPs are defined as those working in general practice, advanced practitioners, paramedics, community matrons, community and district nursing teams, community midwifery teams, dentists and approved mental health professionals. Patients who have immediate life-threatening injuries or illnesses must receive the same level of response in the community irrespective of the source of the 999 calls. The aims of the Framework are to ensure equity of access for all seriously ill or injured patients. It is recognised that in certain situations, an HCP may require immediate clinical assistance to make a life-saving intervention, in addition to ambulance transportation. The Framework maps HCP responses to the Ambulance Response National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 10 January 2025
Programme (ARP) response categories Category 1 (immediate additional clinical assistance from an ambulance service, with a target 7 minute response time) and Category 2 (immediate additional clinical care in hospital, with a target 18 minute response time). Responses to HCP incidents can be measured separately to other 999 activity to examine the parity of responses Where immediate ambulance clinical support and/or transportation is requested by a HCP, it is the responsibility of the referring / attending clinician to make the request to the ambulance trust. It is highly desirable that, if possible, the clinician should not delegate this responsibility – experience has shown that a clear transfer of information is needed. Where delegation is unavoidable, the individual making the request for support should be able to answer triage questions about the patient's condition, including the transfer of information regarding the patient’s history, overall condition and vital signs. HCP Level 1 or HCP Level 2 requests should ordinarily be made by a HCP unless clinical factors require the call to be made by non-clinical staff. However, where calls are made by non-clinical staff on behalf of a HCP, these should be handled in the same way. HCPs can aid the efficient deployment of ambulances by being familiar with the Framework. Equally, ambulance trusts have a responsibility to ensure appropriate clinical support in control rooms and on scene for HCPs dealing with patients with emergency conditions. The Framework includes the question order for HCP requests and the information that HCPs will be asked to provide. Clinicians using the HCP process are advised of both the category of call assigned and an estimated response time based on the current activity level. They are given the option to add anything else once that information is shared and would be able to challenge the category/response based on clinical concern. There are four levels of HCP response: HCP Level 1, HCP Level 2, HCP Level 3 and HCP Level 4. Level 3 may be used for patients who require urgent admission to hospital and has a target response timeframe of 2 hours. Level 4 is for all other patients who do not meet the criteria for Levels 1, 2 or 3 and who require admission to hospital via ambulance for ongoing care, but do not need to be managed as an emergency. This level has a target response time of 4 hours. NHS England collect and publish counts of HCP1, HCP2, HCP3 and HCP4 incidents, and their average response times, at www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Amanda, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 October 2024 concerning the death of Amanda Jane Gainford on 4 November 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Amanda’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Amanda’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Amanda’s family or friends. I realise that responses to Coroner’s Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them. Your Report raised the concern that many healthcare professionals (HCPs) were unaware of their ability to challenge ambulance call hander categorisation and seek a review by a clinician. NHS England has published the National Framework for healthcare professional ambulance responses, which was last updated in March 2021. The Framework is intended for patients who require an ambulance response in a community setting following clinical assessment by a HCP. HCPs are defined as those working in general practice, advanced practitioners, paramedics, community matrons, community and district nursing teams, community midwifery teams, dentists and approved mental health professionals. Patients who have immediate life-threatening injuries or illnesses must receive the same level of response in the community irrespective of the source of the 999 calls. The aims of the Framework are to ensure equity of access for all seriously ill or injured patients. It is recognised that in certain situations, an HCP may require immediate clinical assistance to make a life-saving intervention, in addition to ambulance transportation. The Framework maps HCP responses to the Ambulance Response National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 10 January 2025
Programme (ARP) response categories Category 1 (immediate additional clinical assistance from an ambulance service, with a target 7 minute response time) and Category 2 (immediate additional clinical care in hospital, with a target 18 minute response time). Responses to HCP incidents can be measured separately to other 999 activity to examine the parity of responses Where immediate ambulance clinical support and/or transportation is requested by a HCP, it is the responsibility of the referring / attending clinician to make the request to the ambulance trust. It is highly desirable that, if possible, the clinician should not delegate this responsibility – experience has shown that a clear transfer of information is needed. Where delegation is unavoidable, the individual making the request for support should be able to answer triage questions about the patient's condition, including the transfer of information regarding the patient’s history, overall condition and vital signs. HCP Level 1 or HCP Level 2 requests should ordinarily be made by a HCP unless clinical factors require the call to be made by non-clinical staff. However, where calls are made by non-clinical staff on behalf of a HCP, these should be handled in the same way. HCPs can aid the efficient deployment of ambulances by being familiar with the Framework. Equally, ambulance trusts have a responsibility to ensure appropriate clinical support in control rooms and on scene for HCPs dealing with patients with emergency conditions. The Framework includes the question order for HCP requests and the information that HCPs will be asked to provide. Clinicians using the HCP process are advised of both the category of call assigned and an estimated response time based on the current activity level. They are given the option to add anything else once that information is shared and would be able to challenge the category/response based on clinical concern. There are four levels of HCP response: HCP Level 1, HCP Level 2, HCP Level 3 and HCP Level 4. Level 3 may be used for patients who require urgent admission to hospital and has a target response timeframe of 2 hours. Level 4 is for all other patients who do not meet the criteria for Levels 1, 2 or 3 and who require admission to hospital via ambulance for ongoing care, but do not need to be managed as an emergency. This level has a target response time of 4 hours. NHS England collect and publish counts of HCP1, HCP2, HCP3 and HCP4 incidents, and their average response times, at www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Amanda, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- Merseycare NHS Trust
- NHS England
Response Status
Linked responses
1 of 3
56-Day Deadline
16 Dec 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 09 December 2022 I commenced an investigation into the death of Amanda Jane GAINFORD aged 52. The investigation concluded at the end of the inquest on 23 October 2024. The conclusion of the inquest was that: Amanda was a 52 year old lady detained under Section 2 Mental Health Act on 13/9/22 after a decline in her mental health. Amanda was initially on the Harrington ward before transfer to the Brunswick mental health ward at Broadoak hospital on 5/10/22. Amanda was in poor physical health and had underlying co-morbidities including liver cirrhosis caused by Hepatitis C and alcoholism which caused an enlarged spleen which made it more vulnerable to injury and trauma. Amanda mobilised using a Zimmer frame in part due to having a cast on her leg due to injuries sustained in a road traffic collision a number of years ago, the leg was pending amputation. During her time on both Harrington and Brunswick wards, Amanda was being assessed for a psychotic disorder secondary to polysubstance misuse. Her risks pertained to falls due to immobility, aggression and retaliation of others. During her time on Brunswick ward Amanda was subject to 1:1 level 4 observations at arms length and during her time on both Harrington and Brunswick wards, it was recorded that she had numerous unwitnessed and witness falls and documented incidents of physical aggression. On 24/10/22 Amanda came into conflict with another patient in the corridor in which a verbal altercation led to Amanda pushing the other patient and that patient pushing Amanda back. Amanda proceeded to pick up her Zimmer to her chest and move towards the other patient in which it inadvertently connected with the door fame and the top part of the Zimmer frame subsequently connected with Amanda's upper abdominal area with some force. She subsequently went towards the patient again, at which time the patient extended her leg to prevent Amanda coming closer which connected with her lower abdomen. Amanda thereafter engaged in deliberate actions of banging her head to the toilet wall and throwing herself to the floor in the bathroom and again in her bedroom reopening a cut to her head. Upon clinical assessment at around 5pm, observations were taken which detailed observations all in the normal range but for a low blood pressure. Advice was documented in the RIO notes but it was unclear as to the nature and extent of the advice given to health care staff supporting Amanda thereafter. It was clinically appropriate given Amanda's condition to give intravenous fluids and an ambulance should have been called, neither action was taken and there was a missed opportunity which may have possibly made her injuries survivable. Further blood pressure monitoring was recorded at around 8pm with no records of checks otherwise. Amanda's blood pressure remained low and she presented as pale and jaundiced. A further clinical assessment by the Doctor took place at 8:15pm. Amanda
Official became unresponsive and an IV line was inserted to give fluids. An ambulance was called at 8:24pm by which time it was more likely than not that the prolonged low BP made her injuries unsurvivable. 2 further calls at 8:42pm and 10:04pm were made to the North West Ambulance Service and an ambulance attended noted as a category 2. Amanda was taken by ambulance which arrived at 23:14pm and conveyed her to Whiston hospital where she suffered a cardiac arrest. She was transferred to Aintree hospital and discharged from the Mental Health Act detention on 25/10/22. Amanda died on 4/11/22 at Aintree hospital as a result of multiorgan failure due to splenic laceration and liver cirrhosis, the laceration more likely than not from either the deliberate action with the Zimmer frame or the deliberate falls to the floor on the 24/10/22 after the incident, with the unintended consequence of injury to herself which was fatal.
Official became unresponsive and an IV line was inserted to give fluids. An ambulance was called at 8:24pm by which time it was more likely than not that the prolonged low BP made her injuries unsurvivable. 2 further calls at 8:42pm and 10:04pm were made to the North West Ambulance Service and an ambulance attended noted as a category 2. Amanda was taken by ambulance which arrived at 23:14pm and conveyed her to Whiston hospital where she suffered a cardiac arrest. She was transferred to Aintree hospital and discharged from the Mental Health Act detention on 25/10/22. Amanda died on 4/11/22 at Aintree hospital as a result of multiorgan failure due to splenic laceration and liver cirrhosis, the laceration more likely than not from either the deliberate action with the Zimmer frame or the deliberate falls to the floor on the 24/10/22 after the incident, with the unintended consequence of injury to herself which was fatal.
Circumstances of the Death
See above.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.