Sarah Ferneyhough
PFD Report
Partially Responded
Ref: 2020-0187
Coroner's Concerns (AI summary)
Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.
View full coroner's concerns
1. The deceased’s call was described as an “abandoned call” and thereafter automatically categorised as a category 3 A review of this practice is required.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Ferneyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
2. A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3
3. In the situation leading up to Ms Ferneyhough’s death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the “abandoned” call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the “abandoned” call or provided with full details of any medical information given.
1.
Responses
Action Taken
The Trust has revised its EOC Standard Operating Procedure for Mental Health calls, giving guidance to consider Category 2 response if a call is abandoned and information suggests the patient is actively at risk. An ESOP is also in development to address abandoned calls and will include checks by the control room manager. (AI summary)
The Trust has revised its EOC Standard Operating Procedure for Mental Health calls, giving guidance to consider Category 2 response if a call is abandoned and information suggests the patient is actively at risk. An ESOP is also in development to address abandoned calls and will include checks by the control room manager. (AI summary)
View full response
Dear Ms Beasley-Murray Thank you for your communication regarding the Regulation 28 (Report to Prevent Future Deaths) in respect of the death of Sarah Ferneyhough: would like to offer my condolences to Sarah's family and those affected by this tragic event: can confirm we have distributed the report to the four organisations named in the report as per your request: AACE have confirmed they have reviewed the Trusts response and we are awaiting feedback from the other groups. have responded to the points raised in the Regulation 28 report separately below:
1. The deceased's call was described as an "abandoned call" and thereafter automatically categorised as a Category 3. A review of this practice is required; The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document: Within this ESOP , guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions) , and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call: There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust's governance and approval process_ This will be completed and released in December 2020_ Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include: Chest Pain Breathing Difficulty Loss of consciousness Severe haemorrhage (bleeding) Stroke PregnancylLabour Overdose Chief Executive: Chair: WWW eastamb.nhs.uk #WeAreEEAST
Calls with a mental health element such as suicidal intent, thoughts or threats, serious self- harm or mental health crisis 2 A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than Category 3 The Trust is awaiting a response on national coding but in the meantime has introduced the measures as described above to enable higher risk calls to be escalated and coded as a Category 2 where appropriate
3. In the situation leading up to Ms Ferneyhough's death; the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the "abandoned" call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the "abandoned" call or provided with full details of any medical information given. The ESOP on Abandoned Calls, in development; will now also include a series of checks that must be undertaken by the control room Manager. This includes requirement to listen to the call recording to ensure details given are accurate and the response is appropriate. This will also facilitate clinical escalation and review where required. hope this letter demonstrates the steps the Trust is taking in relation to our management of abandoned calls and calls where there are concerns about a patient's mental health. Please do not hesitate to contact me should you require a further update.
1. The deceased's call was described as an "abandoned call" and thereafter automatically categorised as a Category 3. A review of this practice is required; The Trust has reviewed its process for abandoned calls and specifically those calls relating to potential Mental Health concerns. The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document: Within this ESOP , guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions) , and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end their life, then consideration should be given to responding as a Category 2 call: There is also another ESOP currently in development to address the concerns identified at inquest in relation to abandoned calls and this is currently going through the Trust's governance and approval process_ This will be completed and released in December 2020_ Within this ESOP it is planned that certain calls will be categorised as a Category 2 and examples may include: Chest Pain Breathing Difficulty Loss of consciousness Severe haemorrhage (bleeding) Stroke PregnancylLabour Overdose Chief Executive: Chair: WWW eastamb.nhs.uk #WeAreEEAST
Calls with a mental health element such as suicidal intent, thoughts or threats, serious self- harm or mental health crisis 2 A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than Category 3 The Trust is awaiting a response on national coding but in the meantime has introduced the measures as described above to enable higher risk calls to be escalated and coded as a Category 2 where appropriate
3. In the situation leading up to Ms Ferneyhough's death; the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the "abandoned" call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the "abandoned" call or provided with full details of any medical information given. The ESOP on Abandoned Calls, in development; will now also include a series of checks that must be undertaken by the control room Manager. This includes requirement to listen to the call recording to ensure details given are accurate and the response is appropriate. This will also facilitate clinical escalation and review where required. hope this letter demonstrates the steps the Trust is taking in relation to our management of abandoned calls and calls where there are concerns about a patient's mental health. Please do not hesitate to contact me should you require a further update.
Sent To
- AACE’s National Directors of Operations Group
- Association of Ambulance Chief Executives
- Emergency Call Prioritisation Advisory Group
- National Association of Ambulance Medical Directors
Response Status
Linked responses
1 of 4
56-Day Deadline
16 Dec 2020
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 22 may 2019 I commenced an investigation into the death of Sarah Ferneyhough a 30 year old young woman who died on 22 May 2019 at Abels Road Halstead. The investigation concluded at the end of the inquest on 10 February 2020.
The conclusion of the inquest was expressed as a Narrative viz:- The deceased died at her home address in the early hours of 22 May 2019. She had taken an overdose of venlafaxine, amisulpride and hydroxyzine as well as cocaine, cannabis and alcohol. At 23.53am on 21 May 2019 she called the ambulance service but on attendance of fire and ambulance crews at 3.04am on 22 May she could not be resuscitated. There was a delay in the attendance and failings in the procedures in place for the categorisation of calls. It is not certain whether, if paramedics had arrived sooner, she would have survived. The evidence does not indicate on the balance of probabilities that the deceased intended to take her own life.
The conclusion of the inquest was expressed as a Narrative viz:- The deceased died at her home address in the early hours of 22 May 2019. She had taken an overdose of venlafaxine, amisulpride and hydroxyzine as well as cocaine, cannabis and alcohol. At 23.53am on 21 May 2019 she called the ambulance service but on attendance of fire and ambulance crews at 3.04am on 22 May she could not be resuscitated. There was a delay in the attendance and failings in the procedures in place for the categorisation of calls. It is not certain whether, if paramedics had arrived sooner, she would have survived. The evidence does not indicate on the balance of probabilities that the deceased intended to take her own life.
Circumstances of the Death
See above
The medical cause of death was 1a) alcohol and multiple drug toxicity
The medical cause of death was 1a) alcohol and multiple drug toxicity
Copies Sent To
East of England Ambulance Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.