Jack Goodwin
PFD Report
All Responded
Ref: 2021-0036
All 1 response received
· Deadline: 8 Apr 2021
Coroner's Concerns (AI summary)
The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.
View full coroner's concerns
1. The inquest heard that at the time of the calls to NWAS on 15th December 2017 they were very busy. The script used by the call handler allowed them to indicate that they were busy. However it did not allow for any suggestion or discussion about whether he would be better to make his own way there or allow for the provision by the call handler of a realistic timescale for the ambulance arriving. As a consequence it was difficult for the call maker to make an assessment of the best course of action to ensure that Mr Goodwin received medical attention at the earliest opportunity.
2. When a decision was made to take Mr Goodwin direct to the hospital and NWAS were told. There was no provision within the script to emphasise that the hospital would need to be an acute hospital with an A and E department.
3. There was an indication that given that if Mr Goodwin deteriorated then a further call should be made to NWAS. The evidence before the inquest was that this was not emphasised in such a way within the script to ensure that the call maker understood that this was key to ensure there could be a further assessment of urgency.
2. When a decision was made to take Mr Goodwin direct to the hospital and NWAS were told. There was no provision within the script to emphasise that the hospital would need to be an acute hospital with an A and E department.
3. There was an indication that given that if Mr Goodwin deteriorated then a further call should be made to NWAS. The evidence before the inquest was that this was not emphasised in such a way within the script to ensure that the call maker understood that this was key to ensure there could be a further assessment of urgency.
Responses
Action Planned
NHS England will explore adding guidance to ambulance call scripts to advise callers to go to the nearest emergency department (noting that not all hospitals have them) if they choose to transport the patient themselves. This will be explored through the Ambulance Transformation Forum. (AI summary)
NHS England will explore adding guidance to ambulance call scripts to advise callers to go to the nearest emergency department (noting that not all hospitals have them) if they choose to transport the patient themselves. This will be explored through the Ambulance Transformation Forum. (AI summary)
View full response
Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Jack Goodwin (15 January 2020) Thank you for your Regulation 28 Report to prevent future deaths (hereafter “report”) dated 11 February 2021 concerning the death of Jack Goodwin on 15 January 2020. Firstly, I would like to express my deep condolences to Jack’s family. I am sorry that my response has been delayed. Your report concludes Jack Goodwin’s death was a result of: 1a) Chest infection on a background of hypoxic brain injury 1b) Cardiac arrest 1c) Ischaemic and hypertensive heart disease II) Urinary Tract Infection Following the inquest, you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) about the call script not allowing for discussion about the call maker making their own way to the emergency department or providing a realistic timescale for the ambulance arriving. All ambulance services are responsible for having in place scripts and procedures for dealing with delays in responding when under operational pressure. It is not possible in practice to offer an accurate arrival time for any given patient, but ambulance services will know an approximate current waiting time for that category of patient. NHS E/I support a position that callers should be provided with sufficient information to make informed decisions if an ambulance has not been despatched to the patient. The Ambulance Transformation Forum, chaired by NHS E/I and including representatives from all ambulance services in England, discussed this in April 2021. Following piloting of the provision of an estimated time of arrival it was concluded that providing an accurate estimated time of arrival for an ambulance that had been dispatched to a patient is not practicable, largely due to the common and necessary National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 23 September 2021
practice of diverting lower priority ambulance responses to higher priority incidents. This could lead to patients receiving multiple cancellations and renewed estimated times of arrival. There was strong support for providing more accurate likely waiting times particularly for lower acuity patients. Ambulance services have committed to amending their case exit scripts, where necessary, to provide an estimated waiting time for these lower acuity calls. During the Covid-19 pandemic ambulance services have also enhanced their case exit scripts where significant delays may have occurred to advise callers of the option, due to the long estimated waiting time, that they could make their own way to an emergency department or urgent treatment centre.
Furthermore, you raised the following concerns and I include my response to each in turn:
1) the call script having no provision to emphasise that the patient needed to be taken to an acute hospital with an emergency department
999 calls to the ambulance service can be answered anywhere in the country so we cannot rely on local knowledge; call handlers do not have immediate access to which is the nearest emergency department in those situations where a caller advises that the patient would make their own way to hospital. In appropriate circumstances, NHS E/I consider that advising the caller that they should make their way to the nearest emergency department, noting that not all hospitals have emergency departments, would be a useful addition to the script callers receive. This will be explored through the Ambulance Transformation Forum.
2) the call script did not emphasise in such a way the importance of the call maker making a further call if Mr Goodwin’s condition further deteriorated so that there could be a further assessment of urgency
Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If this was not provided in a clear and easy to interpret manner this is a matter for ambulance services to resolve locally as a training issue for call handlers.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
practice of diverting lower priority ambulance responses to higher priority incidents. This could lead to patients receiving multiple cancellations and renewed estimated times of arrival. There was strong support for providing more accurate likely waiting times particularly for lower acuity patients. Ambulance services have committed to amending their case exit scripts, where necessary, to provide an estimated waiting time for these lower acuity calls. During the Covid-19 pandemic ambulance services have also enhanced their case exit scripts where significant delays may have occurred to advise callers of the option, due to the long estimated waiting time, that they could make their own way to an emergency department or urgent treatment centre.
Furthermore, you raised the following concerns and I include my response to each in turn:
1) the call script having no provision to emphasise that the patient needed to be taken to an acute hospital with an emergency department
999 calls to the ambulance service can be answered anywhere in the country so we cannot rely on local knowledge; call handlers do not have immediate access to which is the nearest emergency department in those situations where a caller advises that the patient would make their own way to hospital. In appropriate circumstances, NHS E/I consider that advising the caller that they should make their way to the nearest emergency department, noting that not all hospitals have emergency departments, would be a useful addition to the script callers receive. This will be explored through the Ambulance Transformation Forum.
2) the call script did not emphasise in such a way the importance of the call maker making a further call if Mr Goodwin’s condition further deteriorated so that there could be a further assessment of urgency
Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If this was not provided in a clear and easy to interpret manner this is a matter for ambulance services to resolve locally as a training issue for call handlers.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Apr 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 16th January 2020 I commenced an investigation into the death of Jack Goodwin. The investigation concluded on the 21stJanuary 2021 and the conclusion was one of narrative: Died from the complications of a hypoxic brain injury that had occurred following a cardiac arrest when there was a significant period before circulation was restored.
The medical cause of death was 1a) Chest Infection on a background of hypoxic brain injury 1b) Cardiac arrest 1c) Ischaemic and hypertensive heart disease II) Urinary Tract Infection
The medical cause of death was 1a) Chest Infection on a background of hypoxic brain injury 1b) Cardiac arrest 1c) Ischaemic and hypertensive heart disease II) Urinary Tract Infection
Circumstances of the Death
On 15th December 2017 Jack Goodwin was at an address in Timperley when he experienced chest pains. Contact was made with the ambulance service at 09:49. The call was categorized as a category 2 call, requiring an average response within 18 minutes and 9 out of 10 within 40 minutes. The call lasted 5 minutes and 19 seconds. Jack Goodwin deteriorated and a decision was taken to drive him to a hospital as it was believed the ambulance was likely to be delayed due to the level of busyness indicated by the call operator.
At 10:01 the ambulance was cancelled and he was en-route to Altrincham Hospital. The hospital chosen did not have an A & E department and is not an acute hospital. At 10:07 a further call was made to NWAS indicating Jack Goodwin was still in the car but was now unconscious. At 10:10 the address (outside Altrincham Hospital) was verified and emergency services were dispatched at 10:12. They arrived at 10:20. That call was categorised at category 1. On arrival of NWAS a defibrillator was being used on Jack Goodwin. He was in ventricular fibrillation.
At 10:44 there was a return of spontaneous circulation and he was transferred to Wythenshawe Hospital. Cardiac investigations found no clear cause of the cardiac arrest. He had sustained a significant hypoxic brain injury as a consequence of the prolonged downtime. He had significant cognitive impairment and as a consequence was at risk of aspiration pneumonia and chest infections. Catheterisation that was required as a consequence of his reduced cognitive function made him susceptible to urinary tract infections. He required significant assistance with daily living. In January 2020 he had deteriorated further and had on the balance of probabilities developed a chest infection.
On 15th January 2020 he died at his home address , Cheadle, from complications arising from the cardiac arrest and prolonged downtime he suffered on 15th December 2017.
At 10:01 the ambulance was cancelled and he was en-route to Altrincham Hospital. The hospital chosen did not have an A & E department and is not an acute hospital. At 10:07 a further call was made to NWAS indicating Jack Goodwin was still in the car but was now unconscious. At 10:10 the address (outside Altrincham Hospital) was verified and emergency services were dispatched at 10:12. They arrived at 10:20. That call was categorised at category 1. On arrival of NWAS a defibrillator was being used on Jack Goodwin. He was in ventricular fibrillation.
At 10:44 there was a return of spontaneous circulation and he was transferred to Wythenshawe Hospital. Cardiac investigations found no clear cause of the cardiac arrest. He had sustained a significant hypoxic brain injury as a consequence of the prolonged downtime. He had significant cognitive impairment and as a consequence was at risk of aspiration pneumonia and chest infections. Catheterisation that was required as a consequence of his reduced cognitive function made him susceptible to urinary tract infections. He required significant assistance with daily living. In January 2020 he had deteriorated further and had on the balance of probabilities developed a chest infection.
On 15th January 2020 he died at his home address , Cheadle, from complications arising from the cardiac arrest and prolonged downtime he suffered on 15th December 2017.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.