Kenneth Adams
PFD Report
All Responded
Ref: 2023-0100Deceased
All 3 responses received
· Deadline: 17 May 2023
Coroner's Concerns (AI summary)
The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to dangerous treatment delays.
View full coroner's concerns
1. During the inquest evidence was heard that:
i. A patient, prescribed either anti platelet or anticoagulant medication, falling and sustaining a scalp laceration that is not "spurting or pouring blood" (the MPDS definition of "uncontrolled bleeding"), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not "spurt or pour" blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as "serious haemorrhage". Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a "serious haemorrhage", the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock.
2. I have concerns with regard to the following:
i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient's predicament and the potential consequences of the continued blood loss.
i. A patient, prescribed either anti platelet or anticoagulant medication, falling and sustaining a scalp laceration that is not "spurting or pouring blood" (the MPDS definition of "uncontrolled bleeding"), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not "spurt or pour" blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as "serious haemorrhage". Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a "serious haemorrhage", the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock.
2. I have concerns with regard to the following:
i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient's predicament and the potential consequences of the continued blood loss.
Responses
Noted
The International Academies of Emergency Dispatch acknowledges the delayed EMS response and identifies contributing factors, including high call volume and Careline's limited information. They suggest that a serious hemorrhage code is equivalent to the initial CAT 3 assignment and that EMDs should stay on the line while providing Dispatch Life Support instructions. (AI summary)
The International Academies of Emergency Dispatch acknowledges the delayed EMS response and identifies contributing factors, including high call volume and Careline's limited information. They suggest that a serious hemorrhage code is equivalent to the initial CAT 3 assignment and that EMDs should stay on the line while providing Dispatch Life Support instructions. (AI summary)
View full response
Dear Sirs RE: Response Regulation 28 Report to Prevent Future Deaths - Kenneth Michael Adams Pursuant to the Coroner's Report received 29th March 2023 ( ), the International Academies of Emergency Dispatch encloses its response to the report. I wish to express my gratitude to your staff who assisted us by obtaining the necessary documentation from the South Western Ambulance Service NHS Foundation Trust, enabling the Academies to fulfill its due diligence to thoroughly review the case and respond accordingly. I wish also to thank you for agreeing to extend the deadline date while all the documentation was collected. If there are questions, or a follow-up is necessary please do not hesitate to contact me.
Action Planned
Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council are reviewing the cross-agency SCARF process, including information sharing and confidentiality, through a project group. A meeting has already taken place to discuss this. (AI summary)
Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council are reviewing the cross-agency SCARF process, including information sharing and confidentiality, through a project group. A meeting has already taken place to discuss this. (AI summary)
View full response
Dear Mr Stewart
Barbara Woodman (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey County Council
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the report carefully, together with senior officers within both organisations.
In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to inform services where they have had contact with an adult who is considered to be vulnerable and/or at risk. It provides information to partner agencies and will often add to the information that the Trust already holds about a person. This could inform further actions that might be taken by the Trust which may include revisions to assessments or care plans.
A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.
Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New SABP NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD
Woodhatch Place 11 Cockshot Hill Reigate RH2 8EF
15 February 2024
Private and Confidential
Year. Any referrals or concerns from the police that require an immediate response there is a clear, well known and well used process for officers, in that they must make contact with either the Emergency Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140 contacts from the Police directly to them.
We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be given as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.
The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, carry out a screening process in respect of SCARF forms received. Appropriate action will then be taken based on the information provided and the risk profile of the person this relates to.
In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.
On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms Woodman’s family that we have reflected on your concerns and provided reassurance as to our processes.
Barbara Woodman (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey County Council
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the report carefully, together with senior officers within both organisations.
In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to inform services where they have had contact with an adult who is considered to be vulnerable and/or at risk. It provides information to partner agencies and will often add to the information that the Trust already holds about a person. This could inform further actions that might be taken by the Trust which may include revisions to assessments or care plans.
A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.
Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New SABP NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD
Woodhatch Place 11 Cockshot Hill Reigate RH2 8EF
15 February 2024
Private and Confidential
Year. Any referrals or concerns from the police that require an immediate response there is a clear, well known and well used process for officers, in that they must make contact with either the Emergency Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140 contacts from the Police directly to them.
We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be given as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.
The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, carry out a screening process in respect of SCARF forms received. Appropriate action will then be taken based on the information provided and the risk profile of the person this relates to.
In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.
On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms Woodman’s family that we have reflected on your concerns and provided reassurance as to our processes.
Action Planned
Kingston upon Hull City Council is planning several measures: relocating taxi ranks, designing a signalized crossing, relocating a crossing facility, considering footpath widening, and implementing a 20mph zone. These are in various stages of feasibility, design, and consultation, with timelines specified. (AI summary)
Kingston upon Hull City Council is planning several measures: relocating taxi ranks, designing a signalized crossing, relocating a crossing facility, considering footpath widening, and implementing a 20mph zone. These are in various stages of feasibility, design, and consultation, with timelines specified. (AI summary)
View full response
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Hull City Council Response
Summary
Based on the identified risks from the coroner’s report relating to “Regulation 28: Report to prevent future deaths (1)” order to take action to prevent future deaths from occurring.
On review the Highway Authority has identified the following preventative measures to be considered. These measures are listed below as Preventative numbers as categorised in the Coroner’s report and are in response to the coroner’s concerns to determine mitigation factors to all risks identified.
Preventative actions HCC proposed to take:
Action ref Action description P1 Relocation of the existing taxi ranks to Alfred Gelder Street.
P2 Design of an increased width, all direction signalised crossing facility at Silver Street/Scale Lane
P3 Relocation of the existing crossing facility on Lowgate closer to Market Place
P4 Proposal to consider the viability of widening the footpaths on Lowgate between Silver Street and Alfred Gelder St
P5 Wider old town area, to be agreed, would become a 20mph zone and additional VMS signs would be installed at either end of the zone.
Timescales
Action ref Timescale P1 Consultation already commenced, HCC is moving into design stage and will commence with legal orders, Summer 2023.
P2 This proposal is in feasibility stage, on receipt of traffic/pedestrian count data, a new design will be formally produced for consultation. Autumn 2023
P3 Item included as part of P2 and will commence in coordination.
P4 Completion of feasibility Autumn 2023 P5 20mph order and consultation Autumn 2023
All preventative measures denoted above will firstly undertake a full design review and feasibility study, the measures will then be carefully considered as options to mitigate concerns
Additionally, to note, none of the measures are set out within the current Highway Capital programme and authorisation to proceed will need to be sought from the Portfolio Holder for Transportation, Highways and Roads. Funding is available to support the design and
development of P1, P2 and P3. Additional funding for the remaining interventions would need to found or other schemes would need to be reprioritised.
From the Regulation 28 Report there were 6no Coroners concerns identified that should be further addressed by the highways authority denoted below.
(1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end.
RESPONSE 01 – Mitigation identified in P1/P2/P3
HCC has further engaged with the Hackney Association with the request to relocate the taxi rank on a permanent basis removing stationary vehicles from Lowgate during the peak night-time economy hours, and during the day.
HCC originally proposed a relocation of the rank to Scale Lane, but a response from the Hackney Association made recommendation to relocate the rank to Alfred Gelder St. HCC are promoting the suggested relocation to Alfred Gelder St and will take action to implement on completion of consultation, design, and any accompanying legal orders.
In the last month the highway authority has procured and carried out investigatory works for counts of vehicle movements, pedestrian counts, and taxi link count surveys.
On receipt of this new data HCC traffic engineers will work towards a feasibility study for a proposed road safety improvement scheme, with a strategic view of providing a new wide crossing facility to the junction of Silver Street and Scale Lane. This option will create a new dedicated crossing at this junction to improve pedestrian safety. Additionally, by relocating the existing crossing to Market Place will improve the pedestrian desire lines further south on Lowgate.
(2) Police raised concerns as follows:
- The road remaining open during a Friday and Saturday night.
- The number of pedestrians using the area.
- Many people in drink in the area having to cross the road.
- The road is a 30 mph.
- Lights of vehicles are distracting
- The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians.
RESPONSE 02 – Mitigation identified in P1/P2/P3/P5
The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity to the A63, the proposals to improve pedestrian safety
in the preventative measures as listed above would negate any requirement for a full road closure and the relocated taxi stand would remove taxis from Lowgate further mitigating 3 point turns in carriageway. Additionally, 3-point turns has been raised with the Hackney Association and it was agreed this would be cascaded to all drivers to cease this manoeuvre on Lowgate.
HCC are progressing the option of reducing the speed limit in the old town wider area to 20mph, with additional VMS signs at either end of the zone as response to improve safety.
(3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”.
RESPONSE 03 – Mitigation identified in P1/P2/P3/P4
A feasibility study has commenced with a view to widening the footway which will ameliorate pedestrian safety. The feasibility study will also include consideration of a slight realignment of the carriageway to provide additional physical traffic calming measures to motorists, The decreased road widths will create an additional preventative measure with the purpose of preventing vehicles stopping on Lowgate.
Consultations with the Hackney Association to relocate the taxi rank away from Lowgate will reduce vehicle movement, the feasibility study includes a dedicated crossing facility and reduced speed limits as identified in response 01/02.
(4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street.
RESPONSE 04 – Mitigation identified in P1/P2/P3/P4
The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity of Lowgate to the A63, additionally the
proposals to improve pedestrian safety in the preventative measures denoted above would negate any requirement for a road closure.
(5) I note the statement from the local authority listed
- They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles.
- The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets.
- That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this.
- The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated.
- Crossing facilities had been looked at but could not be positioned within a suitable distance.
RESPONSE 05 – Mitigation identified in P1/P2/P3/P4
The Highways Authority will be progressing a review of the speed limits within the city centre. Ahead of any wider review Lowgate has been identified as a priority and further consultation will be carried out and meeting minutes taken to identify the key decisions as evidence.
Consultation with Hackney association is ongoing, and agreements will be evidenced.
The road closure will not be pursued given the preventative measures itemised in this response are deemed as satisfactory mitigating factors.
The crossing facilities have been reviewed and are now identified as a project under feasibility study, the item above can now be satisfied after further review of relocation existing crossing as identified in P4
(6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will occur.
RESPONSE 06 – Mitigation identified in P1/P2/P3/P4
The Highway Authority has reviewed the coroners concerns and has identified suitable mitigation measures to address the concerns raised and risks identified and reduce the likelihood of future incidents and severity of outcome.
Summary
Based on the identified risks from the coroner’s report relating to “Regulation 28: Report to prevent future deaths (1)” order to take action to prevent future deaths from occurring.
On review the Highway Authority has identified the following preventative measures to be considered. These measures are listed below as Preventative numbers as categorised in the Coroner’s report and are in response to the coroner’s concerns to determine mitigation factors to all risks identified.
Preventative actions HCC proposed to take:
Action ref Action description P1 Relocation of the existing taxi ranks to Alfred Gelder Street.
P2 Design of an increased width, all direction signalised crossing facility at Silver Street/Scale Lane
P3 Relocation of the existing crossing facility on Lowgate closer to Market Place
P4 Proposal to consider the viability of widening the footpaths on Lowgate between Silver Street and Alfred Gelder St
P5 Wider old town area, to be agreed, would become a 20mph zone and additional VMS signs would be installed at either end of the zone.
Timescales
Action ref Timescale P1 Consultation already commenced, HCC is moving into design stage and will commence with legal orders, Summer 2023.
P2 This proposal is in feasibility stage, on receipt of traffic/pedestrian count data, a new design will be formally produced for consultation. Autumn 2023
P3 Item included as part of P2 and will commence in coordination.
P4 Completion of feasibility Autumn 2023 P5 20mph order and consultation Autumn 2023
All preventative measures denoted above will firstly undertake a full design review and feasibility study, the measures will then be carefully considered as options to mitigate concerns
Additionally, to note, none of the measures are set out within the current Highway Capital programme and authorisation to proceed will need to be sought from the Portfolio Holder for Transportation, Highways and Roads. Funding is available to support the design and
development of P1, P2 and P3. Additional funding for the remaining interventions would need to found or other schemes would need to be reprioritised.
From the Regulation 28 Report there were 6no Coroners concerns identified that should be further addressed by the highways authority denoted below.
(1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end.
RESPONSE 01 – Mitigation identified in P1/P2/P3
HCC has further engaged with the Hackney Association with the request to relocate the taxi rank on a permanent basis removing stationary vehicles from Lowgate during the peak night-time economy hours, and during the day.
HCC originally proposed a relocation of the rank to Scale Lane, but a response from the Hackney Association made recommendation to relocate the rank to Alfred Gelder St. HCC are promoting the suggested relocation to Alfred Gelder St and will take action to implement on completion of consultation, design, and any accompanying legal orders.
In the last month the highway authority has procured and carried out investigatory works for counts of vehicle movements, pedestrian counts, and taxi link count surveys.
On receipt of this new data HCC traffic engineers will work towards a feasibility study for a proposed road safety improvement scheme, with a strategic view of providing a new wide crossing facility to the junction of Silver Street and Scale Lane. This option will create a new dedicated crossing at this junction to improve pedestrian safety. Additionally, by relocating the existing crossing to Market Place will improve the pedestrian desire lines further south on Lowgate.
(2) Police raised concerns as follows:
- The road remaining open during a Friday and Saturday night.
- The number of pedestrians using the area.
- Many people in drink in the area having to cross the road.
- The road is a 30 mph.
- Lights of vehicles are distracting
- The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians.
RESPONSE 02 – Mitigation identified in P1/P2/P3/P5
The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity to the A63, the proposals to improve pedestrian safety
in the preventative measures as listed above would negate any requirement for a full road closure and the relocated taxi stand would remove taxis from Lowgate further mitigating 3 point turns in carriageway. Additionally, 3-point turns has been raised with the Hackney Association and it was agreed this would be cascaded to all drivers to cease this manoeuvre on Lowgate.
HCC are progressing the option of reducing the speed limit in the old town wider area to 20mph, with additional VMS signs at either end of the zone as response to improve safety.
(3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”.
RESPONSE 03 – Mitigation identified in P1/P2/P3/P4
A feasibility study has commenced with a view to widening the footway which will ameliorate pedestrian safety. The feasibility study will also include consideration of a slight realignment of the carriageway to provide additional physical traffic calming measures to motorists, The decreased road widths will create an additional preventative measure with the purpose of preventing vehicles stopping on Lowgate.
Consultations with the Hackney Association to relocate the taxi rank away from Lowgate will reduce vehicle movement, the feasibility study includes a dedicated crossing facility and reduced speed limits as identified in response 01/02.
(4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street.
RESPONSE 04 – Mitigation identified in P1/P2/P3/P4
The closure of the Lowgate has been considered but is not being proposed as mitigation due to the network connectivity of Lowgate to the A63, additionally the
proposals to improve pedestrian safety in the preventative measures denoted above would negate any requirement for a road closure.
(5) I note the statement from the local authority listed
- They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles.
- The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets.
- That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this.
- The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated.
- Crossing facilities had been looked at but could not be positioned within a suitable distance.
RESPONSE 05 – Mitigation identified in P1/P2/P3/P4
The Highways Authority will be progressing a review of the speed limits within the city centre. Ahead of any wider review Lowgate has been identified as a priority and further consultation will be carried out and meeting minutes taken to identify the key decisions as evidence.
Consultation with Hackney association is ongoing, and agreements will be evidenced.
The road closure will not be pursued given the preventative measures itemised in this response are deemed as satisfactory mitigating factors.
The crossing facilities have been reviewed and are now identified as a project under feasibility study, the item above can now be satisfied after further review of relocation existing crossing as identified in P4
(6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will occur.
RESPONSE 06 – Mitigation identified in P1/P2/P3/P4
The Highway Authority has reviewed the coroners concerns and has identified suitable mitigation measures to address the concerns raised and risks identified and reduce the likelihood of future incidents and severity of outcome.
Sent To
- International Academics of Emergency Dispatch
Response Status
Linked responses
3 of 1
56-Day Deadline
17 May 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
Circumstances of the Death
At approximately 3.30am on 19th October 2021, Kenneth Michael Adams, who was prescribed clopidogrel and who lived alone at 60 Vernons Court in Bridport, which is supported housing provided by a housing association, suffered an accidental fall from a standing height, which resulted in a laceration to his scalp. At 4.06 am Mr Adams contacted the ambulance service to explain that he had fallen, injured his scalp and that he could not stop the bleeding. Mr Adams' call was triaged using the Medical Priority Despatch System, which resulted in a disposition of 17-b-01: fall possible dangerous area. This translated to a category 3 ambulance response. The national target set by the Department of Health is to attend category 3 incidents within 120 minutes on at least 90% of occasions (so by 6.13 am), with an average response time of 60 minutes (by 5.13am). At the time of this call, Mr Adams appeared well with no additional symptoms. Mr Adams had also activated his careline, which is an element of the support provided by the housing association. At 7.53 an operator from the careline contacted Mr Adams to check on his welfare. Mr Adams reported that he was now feeling sick, that he was wobbly when stood up and that his bleeding was continuing. The careline operator contacted the ambulance service and advised of the new symptoms. A further triage was conducted, with the same disposition of fall, possibly dangerous area being reached, as the algorithm being used failed to account for the persistent nature of the bleeding being experienced and that Mr Adams was prescribed clopidogrel. At 10.25 Mr Adams again spoke to a careline operator. He was by now slurring his words and his speech was noticeably slow. It is likely he was experiencing symptoms associated with hypovolaemic shock. If Mr Adams had received treatment by 10.25, he would have survived the injury he had sustained. The first ambulance resource arrived at Mr Adams' property at 11.56, by which time a neighbour had found Mr Adams when Mr Adams had called for his help. Mr Adams was conveyed to Dorset County Hospital, where despite treatment he died on 19th October 2021.
Copies Sent To
Appello Limited
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.