Dave Onawelo
PFD Report
Partially Responded
Ref: 2024-0470
Coroner's Concerns (AI summary)
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed to a fatal outcome.
View full coroner's concerns
ln the circumstances it is my statutory duty to report to you. A. Tlru Trusl. l'ällëü tu ädëquätëly lüëiltll'y ä ërltluälly lll pätlëilt wltlr ä pre-uxlstlrrg uu-morbidity, sickle cell anaemia, that carried with it a hiqh risk of acute eterioration. Earlier introduction of fluid resuscitation, blood antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome. d and i/v ln my opinion action should be taken to prevent future deaths and I believe you IAND/OR your organisation] have the power to take such action. ACTION SHOULD BE TAKEN You are under a duty to respond to this report within 56 days of the date of this report, namely by 22"d October 2024lr, the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. othenivise, you must explain why no action is proposed. YOUR RESPONSE
Responses
Noted
The DHSC acknowledges concerns about patient congestion and triaging/care provided to a patient with sickle cell anaemia, noting that the Barts Health NHS Foundation Trust will respond directly with details of actions they are taking. They also mention a government plan to reform the NHS. (AI summary)
The DHSC acknowledges concerns about patient congestion and triaging/care provided to a patient with sickle cell anaemia, noting that the Barts Health NHS Foundation Trust will respond directly with details of actions they are taking. They also mention a government plan to reform the NHS. (AI summary)
View full response
Dear Mr Irvine,
Thank you for the Regulation 28 report of 27th August 2024 sent to the Secretary of State about the death of Dave Yola Onawelo. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Onawelo’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. In particular, your report raised concerns over patient congestion in the local emergency department, and the triaging and level of care provided.
The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. You have raised the concerns about the care Mr Onawelo received directly with the responsible NHS body, the Barts Health NHS Foundation Trust. I understand the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia, and action to increase the number of nurses to help support increased patient demand in the emergency department.
Turning to your concerns on patient congestion and the pressures on the NHS more generally. This government is committed to returning NHS services to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. As a first step, the Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance. This includes maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of
acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 27th August 2024 sent to the Secretary of State about the death of Dave Yola Onawelo. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Onawelo’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. In particular, your report raised concerns over patient congestion in the local emergency department, and the triaging and level of care provided.
The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. You have raised the concerns about the care Mr Onawelo received directly with the responsible NHS body, the Barts Health NHS Foundation Trust. I understand the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia, and action to increase the number of nurses to help support increased patient demand in the emergency department.
Turning to your concerns on patient congestion and the pressures on the NHS more generally. This government is committed to returning NHS services to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. As a first step, the Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance. This includes maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of
acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Barts Health NHS Foundation Trust
- Department of Health and Social Care
Response Status
Linked responses
1 of 2
56-Day Deadline
22 Oct 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
Chief Coroner's Non-Response List
The Chief Coroner has confirmed that the following organisation did not respond within the required period:
Barts Health NHS Foundation Trust
Report Sections
Investigation and Inquest
On 30th December 2023 this court commenced an investigation into the death of Dave Yola Anawelo, aged 34 years old. The investigation concluded at the end of the inquest on 20th August 2024 when the court returned a narrative conclusion. "Dave Yola Onawelo died in hospital on 30th December 2023. Dave suffered from sickle cell anaemia, on the morning of 30th December 2023 he fett unwell and was assessed by paramedics, he was advised to go to hospital but he dectined. Later that day, Dave called a second ambulance and was transferred to Whilst assessmenf Dave deteriorated and suffered an acute respiratory failure caused by an untreated sickle cell crisis. Earlier interuention and treatment may have avoided a fatal outcome." Mr Onawelo's medical cause of death was determined as; 1a Acute respiratory failure 1b Acute chest syndrome 1c Sickle celldisease
Circumstances of the Death
Mr Onawelo was 34 he was diagnosed with sickle cell anaemia. On the morning of 30th December 2023 he felt unwell following a recent sickle cell crisis, he rang 111 an ambulance was sent to his home at 11.56. On assessment a|12.40 Dave had a moderately fast breathing and heart rate and high blood pressure, his pain was assessed as 6/10. Mr Onawelo was observed to have good oxygen saturation levels and no temperature. Dave was advised to attend hospital, but he declined. Later that afternoon Dave called for an ambulance due to a change in presentation, he had developed difficulty in breathing. Clinical observations at 16.38 were unchanged, he agreed to go to hospital. At the local emergency department ("ED") a handover occurred at 17.23, at this time Dave was not examined and no clinical observations or bloods were taken. A117.27, Dave was assessed, he explained that he believed that he was in a sickle cell crisis, partial observations were taken and he was deemed not to be acutely unwell and therefore suitable for the lnitial Assessment ("14") section of the ED. He and his mother were asked to remain in the waiting area. Whilst waiting, Mrs Onawelo became concerned regarding her son's deterioration and sought attention from hospital staff. A streamer told her that she was being anxious and a senior nurse refused to assist telling Mrs Onawelo that she was "busy with 6 acute patients". lt was only at '18.49 when Mrs Onawelo confronted medical and nursing staff within the lA section that a nurse checked upon Dave. Mr Onawelo appeared drowsy and was slouched to one side. Dave was taken into the lA section in a wheelchair and observations were taken which showed values consistent as those observed earlier, his chest was auscultated and found to be clear. Whilst being cannulated a doctor noticed that Dave appeared unwell and so made provision for him to be taken into a resuscitation bay. Dave then began to experience seizures and sustained a cardiac arrest. A venous blood gas test demonstrated that Dave was profoundly anaemic and acidotic, he had raised lactate and potassium levels and a critically low blood sugar level. Resuscitative efforts were commenced but discontinued at 19.48
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.