UK Inquiry Tracker

Joseph Miller

PFD Report All Responded Ref: 2024-0142

Date of Report 14 March 2024

Coroner Alison Mutch

Coroner Area Manchester South

Response Deadline est. 9 May 2024

Alcohol, drug and medication related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 9 May 2024

Coroner's Concerns (AI summary)

Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.

View full coroner's concerns

1. The inquest heard evidence that different ambulance services use different pathways that can impact how calls are categorised /downgraded. The consequence of this is that how the ambulance services across England deal with a call varies depending on where you live. As an example in this inquest, because of where Joseph lived, calls can go to EMAS or NWAS depending on which mobile telephone mast the call pings on. The initial call went to EMAS who on being told he was no longer fitting downgraded the call, in line with their pathway. The inquest was told that had the call been dealt with by NWAS they would not have downgraded the call to a category 3 in this situation because that was not how their pathway operated.
2. The consequence of these different pathways is that there is not a consistent approach to call categorisation across the country which can have a significant impact on the dispatch of potentially lifesaving attendance by the ambulance service.

Responses

Department of Health and Social Care Central Government

14 Jun 2024

Noted
The Department of Health and Social Care acknowledges the concerns regarding ambulance call triage systems and notes that NHS England has a process to map 999 call triage system outcomes against ambulance response time categories. The Emergency Call Prioritisation Advisory Group (ECPAG) keeps the categorisation of calls under continual review. (AI summary)

View full response

Dear Ms Mutch,

Thank you for your letter of 14 March 2024 to the Secretary of State for Health and Social Care Victoria Atkins, about the death of Joseph Michael Miller. I am replying as Minister with responsibility for urgent and emergency services.

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Miller’s death and I offer my sincere condolences to his family. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention.

Your report raised concerns about the two call triage systems in use by NHS ambulance trusts, and the potential for patients to be given a different ambulance categorisation depending on the system used. The Department’s officials have shared your report with the East Midlands Ambulance Service (EMAS), North West Ambulance Service (NWAS) and NHS England (NHSE) as the body responsibly for oversight of NHS ambulance services.

Ambulance services are required to use an approved triage system to aid initial 999 call prioritisation – the two approved systems are the Advanced Medical Dispatch Priority System (AMPDS) and the NHS Pathways system. These systems are approved on the basis of being able to determine (as far as possible) differing levels of acuity, from immediately life- threatening emergencies to patients with an urgent care need.

In considering the concerns raised about the potential for variation between categorisation, NHSE has advised the Department that it has in place a process to appropriately map the outcomes of 999 call triage systems against ambulance response time categories. NHSE has responsibility for the production, maintenance, review and revision of the dataset used in these systems, which is managed by the NHSE-chaired Emergency Call Prioritisation Advisory Group (ECPAG). ECPAG keeps the categorisation of calls under continual review, and ambulance services support this process through providing evidence and expertise to reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England.

Thank you once again for bringing these concerns to my attention.

Yours,

HELEN WHATELY

Sent To

Department of Health and Social Care

Response Status

Linked responses 1 of 1

56-Day Deadline 9 May 2024

All responses received

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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 6th June 2023 I commenced an investigation into the death of Joseph Michael Miller. The investigation concluded on the 2nd February 2023 and the conclusion was one of narrative: Died from the complications of a seizure contributed to by the use of cocaine. The medical cause of death was 1a) Hypoxic Brain Injury 1b) Cardiac Arrest on the background of a seizure and cocaine use

Circumstances of the Death

On the 31st May 2023, Joseph Michael Miller was seen by a neighbour to be fitting in the garden of his home address. A call was made to the ambulance service that was initially categorised as category 1 but downgraded to category 3 when it was reported that he was no longer fitting. A further call was made when he had another seizure and became unconscious. Ambulance crews attended. The initial Rapid Response Team were there within eight minutes. He did not return to consciousness despite extensive efforts to resuscitate him. He was transferred to Tameside General Hospital where tests on the 3rd June confirmed severe hypoxic brain injury and he was declared dead on 5th June.