Peggy Copeman
PFD Report
All Responded
Ref: 2021-0182
All 1 response received
· Deadline: 20 Jul 2021
Coroner's Concerns (AI summary)
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff member was CPR trained, violating policy.
View full coroner's concerns
1. PRAS Conveyance Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive … “
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that
“the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services
3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective
4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them
5. Only one member of staff out of three had training in CPR
6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters
7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that
“the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy
Responses
Action Taken
Premier Rescue Ambulance Service Ltd. has trained all staff, including drivers, in CPR, with one member of staff now authorized to train others internally. The company has also implemented a policy to no longer transport patients who are not awake and responsive at the start of the journey and requires a qualified medical practitioner confirming a patient's fitness to travel. (AI summary)
Premier Rescue Ambulance Service Ltd. has trained all staff, including drivers, in CPR, with one member of staff now authorized to train others internally. The company has also implemented a policy to no longer transport patients who are not awake and responsive at the start of the journey and requires a qualified medical practitioner confirming a patient's fitness to travel. (AI summary)
View full response
Response of Premier Rescue Ambulance Service Ltd to Regulation 18 Notice This Response is sent in response to Regulation 18 Notice dated 28th May 2021 and is sent on behalf of Premier Rescue Ambulance Service Ltd.
1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are tG have training in relation to CPR. As a consequence of this de.cision, has attended the following courses: a) First Aid Assessors and Internal Quality Assurance CPD Training 31st January 2020 b) level 3 Award in Education and Training- 10th February 2020 c) Cardiopulmonary Resuscitation and Automated External Defibrillation
- 29th January 2020 d) · First Aid at Work Instructor - 31st January 2020 e) First Aid at Work- 31st January 2020 f) Immediate Management of Anaphylaxis Instructor- 30th January 2020 g) Oxygen Therapy Administration - 30th January 2020 h) Oxygen Therapy Administration Instructor - 30th January 2020 i) Defibrillation Instructor - 29th January 2020 Certificates attached
As a consequence of the training, is now authorised to train others within Premier Rescue Ambulance Services Ltd.
2. As a consequence of the training, 12 staff have received internal training and the 8 remaining staff hold valid external certificates. Upon expiry of those external certificates, internal training will be provided. A copy of the relevant Training Manual is attached.
3. In the current case Premier Rescue Ambulance Service Ltd., accept that only one member of staff had been fully trained in basic life support. The above courses and training seeks to address that deficit. The intention is that in future ALL members of staff conveying patients will have received basic life support training, including drivers of the vehicles. The course will cover recognition of cardiac arrest and recognising distress in patients.
4. Premier Rescue Ambulance Service Ltd., merely observe that the request to transfer Peggy Copeman was received late in the afternoon of the lSth December with a request to transfer her on the morning of the 16th December. Accepting instructions such as this in such a short timeframe has been identified by the Company as a weakness in procedures which led to two untrained staff accompanying one trained member of staff.
5. The Company regret their initial investigation did not highlight
or as not having CPR training. They have now revised their internal investigation procedure and they are now investigating the possibility of a qualified independent assessor carrying out such a role in the future should the need arise. In the meantime, any internal investigation pending such an appointment will be carried out by
. who is a State Registered Nurse and has undergone iuff trilmtng by NUCO as Htwt ~ly. The dlanges. m lnter'181 imrestiptlo11area> beimplemented: immediately.
6. !n:the meantimerltie<tara.Quality Commission•have seNed aSNl)ensio11 · ~ upon prem(er ~e~we Ambu1anee Sl':ITTlite ltd.; p-g a hl.lltto tOll\leyante danypatfent until at least.the.end d.July. ~ter,•fte$(Ue Amt>•teseMi:~ Ltd;, have now imp1emem:ed a Poli~ Ulat~arenQ l~ger p!'li}pa~ tQ. a.~tor~nsl)J)rtpatient$ wh<> are not awake and re!ilponsive at the tommencemellt d tilejourney., This is so'the\!tan ~ally~~anytha~s.in ffil!irbehavio~ron theJQ~ey, They wm also. tf:!<l1J~re a sip~ ~ument ~ a qtialffi~ Medltal Practitioner confirming a patie.nt's ftmess to travel 11nd also require a d$i'led ll$tofmer:t~~nspa~t$~ reteMng·so ilsto.enablet~t-0 <:alTJ mat 1t .risk a~ent as to whether It Is asrpmprlate tor those
p.itfflats·m..betransfetredby·Premier~eA.mbijlil~Servi<:eltd•.The detaiki!d list d meditatJQilS willbe .r~ewed by and . ·Tuose.Potides h.webHII implemented 1mmedtately. Signed:
1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are tG have training in relation to CPR. As a consequence of this de.cision, has attended the following courses: a) First Aid Assessors and Internal Quality Assurance CPD Training 31st January 2020 b) level 3 Award in Education and Training- 10th February 2020 c) Cardiopulmonary Resuscitation and Automated External Defibrillation
- 29th January 2020 d) · First Aid at Work Instructor - 31st January 2020 e) First Aid at Work- 31st January 2020 f) Immediate Management of Anaphylaxis Instructor- 30th January 2020 g) Oxygen Therapy Administration - 30th January 2020 h) Oxygen Therapy Administration Instructor - 30th January 2020 i) Defibrillation Instructor - 29th January 2020 Certificates attached
As a consequence of the training, is now authorised to train others within Premier Rescue Ambulance Services Ltd.
2. As a consequence of the training, 12 staff have received internal training and the 8 remaining staff hold valid external certificates. Upon expiry of those external certificates, internal training will be provided. A copy of the relevant Training Manual is attached.
3. In the current case Premier Rescue Ambulance Service Ltd., accept that only one member of staff had been fully trained in basic life support. The above courses and training seeks to address that deficit. The intention is that in future ALL members of staff conveying patients will have received basic life support training, including drivers of the vehicles. The course will cover recognition of cardiac arrest and recognising distress in patients.
4. Premier Rescue Ambulance Service Ltd., merely observe that the request to transfer Peggy Copeman was received late in the afternoon of the lSth December with a request to transfer her on the morning of the 16th December. Accepting instructions such as this in such a short timeframe has been identified by the Company as a weakness in procedures which led to two untrained staff accompanying one trained member of staff.
5. The Company regret their initial investigation did not highlight
or as not having CPR training. They have now revised their internal investigation procedure and they are now investigating the possibility of a qualified independent assessor carrying out such a role in the future should the need arise. In the meantime, any internal investigation pending such an appointment will be carried out by
. who is a State Registered Nurse and has undergone iuff trilmtng by NUCO as Htwt ~ly. The dlanges. m lnter'181 imrestiptlo11area> beimplemented: immediately.
6. !n:the meantimerltie<tara.Quality Commission•have seNed aSNl)ensio11 · ~ upon prem(er ~e~we Ambu1anee Sl':ITTlite ltd.; p-g a hl.lltto tOll\leyante danypatfent until at least.the.end d.July. ~ter,•fte$(Ue Amt>•teseMi:~ Ltd;, have now imp1emem:ed a Poli~ Ulat~arenQ l~ger p!'li}pa~ tQ. a.~tor~nsl)J)rtpatient$ wh<> are not awake and re!ilponsive at the tommencemellt d tilejourney., This is so'the\!tan ~ally~~anytha~s.in ffil!irbehavio~ron theJQ~ey, They wm also. tf:!<l1J~re a sip~ ~ument ~ a qtialffi~ Medltal Practitioner confirming a patie.nt's ftmess to travel 11nd also require a d$i'led ll$tofmer:t~~nspa~t$~ reteMng·so ilsto.enablet~t-0 <:alTJ mat 1t .risk a~ent as to whether It Is asrpmprlate tor those
p.itfflats·m..betransfetredby·Premier~eA.mbijlil~Servi<:eltd•.The detaiki!d list d meditatJQilS willbe .r~ewed by and . ·Tuose.Potides h.webHII implemented 1mmedtately. Signed:
Sent To
- Premier Rescue Ambulance Services
Response Status
Linked responses
1 of 1
56-Day Deadline
20 Jul 2021
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 08/01/2020 I commenced an investigation into the death of Peggy Joan COPEMAN aged 81. The inquest has not yet been heard
Circumstances of the Death
Mrs Peggy Copeman was placed under s 2 MHA on 10.12.2019 and was taken to Cygnet Hospital, Taunton on 12.12.2020. She was being transported back to Norfolk on 16.12.2019 by Premier Rescue Ambulance Service (PRAS). PRAS transfers patients to or from a healthcare facility or other such location, providing care during transit. During the journey Mrs Copeman had altered breathing. When driving along the M11 a short distance prior to junction 9, Mrs Copeman was noted to have mucous coming from her nose and the ambulance pulled over on the hard shoulder. Mrs Copeman was noted to be unresponsive. Telephone calls were made to Cygnet House and PRAS and then emergency services were called. Mrs Copeman was declared dead at the scene.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.