James Campion
PFD Report
Partially Responded
Ref: 2023-0539
Coroner's Concerns (AI summary)
Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision of medical and psychiatric assistance for an overdose.
View full coroner's concerns
The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
Responses
Action Planned
The Department of Health and Social Care mentioned plans to improve A&E waiting times, reduce ambulance response times, expand mental health services through NHS111, and invest in mental health infrastructure. They are also deploying mental health professionals in 999 call centers and clinical assessment services. (AI summary)
The Department of Health and Social Care mentioned plans to improve A&E waiting times, reduce ambulance response times, expand mental health services through NHS111, and invest in mental health infrastructure. They are also deploying mental health professionals in 999 call centers and clinical assessment services. (AI summary)
View full response
Dear Anita,
Thank you for your Regulation 28 report to prevent future deaths dated 20 December 2023 about the death of James Campion. I am replying as the Minister with responsibility for mental health and patient safety.
Firstly, I would like to say how saddened I was to read of the circumstances of James’ 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. Please accept my sincere apologies for the significant delay in responding to this matter.
Your report raises concerns over delays in the dispatch of ambulance and the provision of urgent and emergency mental health care.
The Department recognises the significant pressure the urgent and emergency care system is facing. That is why we published our Delivery plan for recovering urgent and emergency care services, which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at: www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for- recovering-urgent-and-emergency-care-services.pdf
Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.
At a national level, we have seen significant improvements in performance this year compared to last year. For example, in 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13
minutes faster compared to 2022/23, a reduction of over 27%. NWAS’ average Category 2 response times were over 13 minutes faster, a 32% reduction.
We have also made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.
The Government is committed to improving urgent mental health services. We have now made emergency mental health support through NHS111 available everywhere in England. For those with severe needs or in crisis, 24/7 urgent mental health helplines are already available in all areas of the country. These crisis lines currently take around 200,000 calls a month. Linking these through to NHS111 will provide a consistent route for people to access support across the country. Delivering this commitment will enable anyone experiencing mental health crisis to access assessment and, if appropriate, onward referral and treatment at any time of the day by calling NHS111.
It will mean that when an individual calls the NHS111 mental health option, a trained mental health professional will answer the call. They will often ask a number of important mental health related questions, which can lead to a number of outcomes including signposting and guidance, as well as onward referrals to other services.
To supplement this new NHS111 offer, we are also deploying mental health professionals in 999 call centres and clinical assessment services to help ensure that people experiencing a mental health crisis are directed towards appropriate services.
The Government also invested £98 million into NHS111 in 2021/22 to boost staff numbers, increasing call taking and clinical advice capacity, helping patients at home and avoiding unnecessary ambulance calls and conveyances to A&E. This was followed in 2022-23 with an extra £50 million to support additional NHS111 capacity.
In addition, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co- occurring physical and mental health issues.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for your Regulation 28 report to prevent future deaths dated 20 December 2023 about the death of James Campion. I am replying as the Minister with responsibility for mental health and patient safety.
Firstly, I would like to say how saddened I was to read of the circumstances of James’ 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. Please accept my sincere apologies for the significant delay in responding to this matter.
Your report raises concerns over delays in the dispatch of ambulance and the provision of urgent and emergency mental health care.
The Department recognises the significant pressure the urgent and emergency care system is facing. That is why we published our Delivery plan for recovering urgent and emergency care services, which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at: www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for- recovering-urgent-and-emergency-care-services.pdf
Your report highlights that North West Ambulance Service (NWAS) was under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.
At a national level, we have seen significant improvements in performance this year compared to last year. For example, in 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13
minutes faster compared to 2022/23, a reduction of over 27%. NWAS’ average Category 2 response times were over 13 minutes faster, a 32% reduction.
We have also made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.
The Government is committed to improving urgent mental health services. We have now made emergency mental health support through NHS111 available everywhere in England. For those with severe needs or in crisis, 24/7 urgent mental health helplines are already available in all areas of the country. These crisis lines currently take around 200,000 calls a month. Linking these through to NHS111 will provide a consistent route for people to access support across the country. Delivering this commitment will enable anyone experiencing mental health crisis to access assessment and, if appropriate, onward referral and treatment at any time of the day by calling NHS111.
It will mean that when an individual calls the NHS111 mental health option, a trained mental health professional will answer the call. They will often ask a number of important mental health related questions, which can lead to a number of outcomes including signposting and guidance, as well as onward referrals to other services.
To supplement this new NHS111 offer, we are also deploying mental health professionals in 999 call centres and clinical assessment services to help ensure that people experiencing a mental health crisis are directed towards appropriate services.
The Government also invested £98 million into NHS111 in 2021/22 to boost staff numbers, increasing call taking and clinical advice capacity, helping patients at home and avoiding unnecessary ambulance calls and conveyances to A&E. This was followed in 2022-23 with an extra £50 million to support additional NHS111 capacity.
In addition, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co- occurring physical and mental health issues.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
- NHS England
- NHS Improvement
Response Status
Linked responses
1 of 3
56-Day Deadline
14 Feb 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 02 August 2022 I commenced an investigation into the death of James CAMPION aged
57. The investigation concluded at the end of the inquest on 19 December 2023. The conclusion of the inquest was that: Narrative Conclusion : The consumption of an excessive amount of prescription medication whilst under the influence of alcohol, contributed to by the delay in medical treatment.
57. The investigation concluded at the end of the inquest on 19 December 2023. The conclusion of the inquest was that: Narrative Conclusion : The consumption of an excessive amount of prescription medication whilst under the influence of alcohol, contributed to by the delay in medical treatment.
Circumstances of the Death
James Campion was 57 year old gentleman who had a number of co-morbidities, including a history of depression and previous drug overdoses. Mr Campion was also known to drink alcohol to excess, described by family as a functioning alcoholic. On 1 July 2022 Mr Campion contacted the crisis teams indicated he was going to overdose and then proceeded to overdose on prescription medication. He was conveyed to the Royal Liverpool University Hospital where he was treated for the overdose and seen by the mental health team. A mental health assessment was not carried out and he was discharged with the advice to contact the crisis team if needed. On the evening of 20 July 2022 Mr Campion spoke to a friend who confirms Mr Campion appeared intoxicated but appeared to be his normal self. In the early hours of 21 July 2022, Mr Campion made contact with the Psychiatric Crisis Team threatening to take an overdose of and his heart medication, he also stated that he had been drinking vodka. In the light of their concerns the Crisis Team contacted the North West Ambulance Service (NWAS) by 999 at 2.10am. The initial call was allocated a category III classification (attendance within one hour and 90% of calls within two hours). The Service was stated to be very busy at that time. It was four and a half hours from the original call before the case was reviewed by a clinician but there does not appear to have been a welfare check phone call at that time. It was not until six hours after the initial call that an ambulance was allocated and when the crew arrived at his home address at 8:26am they found Mr Campion deceased in the living room. The post mortem and toxicology investigation found the cause of death to be mirtazapine and alcohol toxicity. Mirtazapine is an antidepressant medication and has a number of common side-effects including feeling sleepy and in overdose it can lead to reduced consciousness and coma. The TOXBASE guidance notes that peak plasma concentrations occur approximately two hours after ingestion. It also states that the effects on the central nervous system may be enhanced or prolonged following co-ingestion of other central nervous system depressants including alcohol. Though it is unknown as to exactly what time Mr Campion took the overdose of mirtazapine, in the opinion of the expert the delay of over 6 hours from the initial call to the ambulance service to an ambulance crew being allocated and arriving on scene is very significant. It is more likely than not if Mr Campion had been in hospital at a point at least two hours after ingestion he would have survived this event. There were a number of missed opportunities in the care and treatment of Mr Campion. The family contact details noted by the mental health team were incorrect. There was very little evidence of family involvement throughout the mental health interactions, this being a critical and crucial element of the mental heath treatment plan. On 1 July 2022 a full mental health assessment should have been carried out, which is likely to have resulted in immediate support for Mr Campion and measures been put in place for further referrals to the appropriate mental health services. On 21 July 2022 the ambulance call handler did not give the time estimate of the ambulance to the crisis team member; that said the numbers for the family were incorrect and so would not have led to anyone being contacted. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Mr Campion clearly consumed an excessive amount of prescription medication whilst under the influence of alcohol and as such his state of mind is likely to have been impaired. Taking account of his past actions, particularly that of 1st July 2022, it is more likely than not he carried out the act not with the intention of taking his own life.
Copies Sent To
North West Ambulance Service Mersey Care NHS Foundation Trust Merseyside Police
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.