Christopher Locke
PFD Report
All Responded
Ref: 2023-0310
All 1 response received
· Deadline: 19 Oct 2023
Coroner's Concerns (AI summary)
Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders in such environments.
View full coroner's concerns
1. In a pub environment there is a greater chance for the public to sustain injuries that requires emergency treatment
2. Ordinary bystanders’ ability to administer emergency treatment may be hindered by their own consumption of alcohol
3. Whilst the primary responsibility of staff is to comply with EMD directions they are deprived of the opportunity to provide lifesaving treatment in circumstances that warrant it if that training is not offered
4. Staff would not know the circumstances that warrant it without the benefit of CPR training.
2. Ordinary bystanders’ ability to administer emergency treatment may be hindered by their own consumption of alcohol
3. Whilst the primary responsibility of staff is to comply with EMD directions they are deprived of the opportunity to provide lifesaving treatment in circumstances that warrant it if that training is not offered
4. Staff would not know the circumstances that warrant it without the benefit of CPR training.
Responses
Noted
JD Wetherspoon expresses condolences but states they will not change their policy of relying on emergency services for medical care, rather than providing CPR training to staff, citing advice from their Primary Authority. (AI summary)
JD Wetherspoon expresses condolences but states they will not change their policy of relying on emergency services for medical care, rather than providing CPR training to staff, citing advice from their Primary Authority. (AI summary)
View full response
Response to Regulation 28 Report – Christopher Locke Deceased
J D Wetherspoon PLC (“Wetherspoon”) was very sorry to have learnt about the passing of Mr Locke. On hearing evidence at the Inquest we understand why the Coroner has raised the Regulation 28 Report. We are aware that the Coroner has also contacted a trade body to also look into the provision of CPR training across the wider licensed industry.
We note that incorrect evidence was given by Wetherspoon employees at the Inquest to the effect that “there had previously been a scheme offered to undertake additional training including CPR training”. That position is not correct.
Wetherspoon have a policy that if any customers or staff get into a medical emergency, care is provided by appropriately trained medical professionals. It is therefore Wetherspoon’s policy that for any injury or medical incident that requires immediate attention, emergency services are called and an ambulance is requested. Wetherspoon does not provide or offer medical training (which would include CPR training) to its staff as it feels a qualified medical professional is best place to provide it. This policy has been in place for 25 years and has been reviewed by and assured advice has been received from Wetherspoon’s Primary Authority.
Wetherspoon has reviewed the position in relation to offering CPR training since receiving the Regulation 28 Report but will not be making any changes to the existing policy.
J D Wetherspoon PLC (“Wetherspoon”) was very sorry to have learnt about the passing of Mr Locke. On hearing evidence at the Inquest we understand why the Coroner has raised the Regulation 28 Report. We are aware that the Coroner has also contacted a trade body to also look into the provision of CPR training across the wider licensed industry.
We note that incorrect evidence was given by Wetherspoon employees at the Inquest to the effect that “there had previously been a scheme offered to undertake additional training including CPR training”. That position is not correct.
Wetherspoon have a policy that if any customers or staff get into a medical emergency, care is provided by appropriately trained medical professionals. It is therefore Wetherspoon’s policy that for any injury or medical incident that requires immediate attention, emergency services are called and an ambulance is requested. Wetherspoon does not provide or offer medical training (which would include CPR training) to its staff as it feels a qualified medical professional is best place to provide it. This policy has been in place for 25 years and has been reviewed by and assured advice has been received from Wetherspoon’s Primary Authority.
Wetherspoon has reviewed the position in relation to offering CPR training since receiving the Regulation 28 Report but will not be making any changes to the existing policy.
Sent To
- JD Wetherspoon PLC
Response Status
Linked responses
1 of 1
56-Day Deadline
19 Oct 2023
All responses received
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 the 11th August 2022 I commenced an investigation into the death of Christopher James Locke. The investigation concluded at the end of the inquest on the 24th of August 2023.
The medical cause of death is 1a) hypoxic ischaemic encephalopathy 1b) cardiac arrest 1c) cardiac arrhythmia in a man with a fatty heart who had sustained a blow to the head
The conclusion of the inquest as to how Mr Locke came to his death was a narrative conclusion and is as follows:-
The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased’s death
The medical cause of death is 1a) hypoxic ischaemic encephalopathy 1b) cardiac arrest 1c) cardiac arrhythmia in a man with a fatty heart who had sustained a blow to the head
The conclusion of the inquest as to how Mr Locke came to his death was a narrative conclusion and is as follows:-
The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased’s death
Circumstances of the Death
The deceased was Christopher James Locke and he was pronounced dead on the 29th October 2021 at Morriston Hospital, Swansea. The cause of death was hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac.
Christopher was admitted to Morriston Hospital via UHW Hospital Cardiff on the 23rd October 2021 having sustained a cardiac arrest at the Lord Cradoc public house, Port Talbot during the evening of the 21st of October 2021. The cause of the cardiac arrest was found to be a cardiac arrhythmia. The staff at the Lord Cradoc called 999 and followed the instructions provided by the Emergency Medical Dispatcher (EMD). The EMD did not instruct the staff to undertake CPR. Christopher’s circulation was restored 12 minutes after the arrival of the paramedics, who arrived 8 minutes after the commencement of the call. It was therefore estimated that Christopher had been without oxygen for at least 20 minutes. Christopher died from a brain injury caused by this lack of oxygen.
Christopher was admitted to Morriston Hospital via UHW Hospital Cardiff on the 23rd October 2021 having sustained a cardiac arrest at the Lord Cradoc public house, Port Talbot during the evening of the 21st of October 2021. The cause of the cardiac arrest was found to be a cardiac arrhythmia. The staff at the Lord Cradoc called 999 and followed the instructions provided by the Emergency Medical Dispatcher (EMD). The EMD did not instruct the staff to undertake CPR. Christopher’s circulation was restored 12 minutes after the arrival of the paramedics, who arrived 8 minutes after the commencement of the call. It was therefore estimated that Christopher had been without oxygen for at least 20 minutes. Christopher died from a brain injury caused by this lack of oxygen.
Inquest Conclusion
-
The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased’s death
The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased’s death
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.