Helen Sheath
PFD Report
All Responded
Ref: 2020-0107
All 1 response received
· Deadline: 24 Mar 2020
Coroner's Concerns (AI summary)
Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
View full coroner's concerns
(1) Helen’s father first called ambulance services at 18.20 hours on 2018 which was before she had ingested the sodium nitrate. EEAS’s investigation report stated that “from the information provided on this call, that Helen had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled “Psychiatric/Abnormal Behaviour/Suicide Attempt” and the call was coded as a Category 3. This call has been audited by the Quality Assurance Team and was correctly coded and the correct set of questions used” ….yet a Category 3 call is for patients who have potentially urgent conditions that are not life threatening and yet Helen had a history of suicide ideation and her father was unable to tell, being the other side of the locked door, whether the substance had been taken or not. In view of both Helen’s past medical history and the fact that her father had no knowledge as to whether the substance had been ingested or not at that stage, it seemed to the Court that an assumption that an overdose had been taken ought to have been made and this first call, therefore, coded as a Category 2; (2) Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call and it was only after a second call was made to ambulance services at 18.48 hours, when the call handler selected the set of questions titled “Overdose/Poisoning/Ingestion” because it was said that it was suggested on this call that she had ingested the substance that the call was coded a Category 2 and that, due to the lack of DSA availability, at 18.57 hours a Rapid Response Vehicle (RRV) was dispatched with the Mental Health Street Triage Team who arrived at 19.05 and 19.11 hours respectively with a different DSA arriving at 19.25 hours.
(3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.
(3) If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.
Responses
Noted
The Association of Ambulance Chief Executives (AACE) outlines the triage process for 999 calls, the role of the Emergency Call Prioritisation Advisory Group (ECPAG), and references a letter sent to ambulance trusts in April 2019 from NHS England regarding clinical oversight for self-harm and suicidal patients. NASMeD previously encouraged all ambulance trusts to implement clinical review of these cases. (AI summary)
The Association of Ambulance Chief Executives (AACE) outlines the triage process for 999 calls, the role of the Emergency Call Prioritisation Advisory Group (ECPAG), and references a letter sent to ambulance trusts in April 2019 from NHS England regarding clinical oversight for self-harm and suicidal patients. NASMeD previously encouraged all ambulance trusts to implement clinical review of these cases. (AI summary)
View full response
Dear Ms Whitting
REGULATION 28: HELEN SHEATH
I am writing in response to the Regulation 28 report to prevent future deaths following the inquest into the death of Helen Sheath which you issued on 29th April 2020 to the Association of Ambulance Chief Executives (AACE), National Ambulance Service Medical Directors (NASMeD) and Emergency Call Prioritisation Advisory Group (ECPAG).
AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service however we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. One of our specialist sub groups is the National Ambulance Service Medical Directors (NASMeD) and this response therefore is from AACE and has been informed by NASMeD.
The response categories are set by the Emergency Call Prioritisation Advisory Group (ECPAG), an NHS England led group responsible for the governance, control and approval of any change to clinical code sets (aligning codes to response categories).
When 999 is called, the call is assessed by using a triage tool. East of England Ambulance Service and four other ambulance trusts in England use AMPDS and the other five trusts use NHS pathways. The 999 call taking staff are trained to use these systems and follow a set of questions that relates to the information that is given to them over the telephone and they have to follow a defined process which then determines the category of response. This ensures that all calls are appropriately categorised so that patients with life threatening conditions receive the most appropriate and timely response. This does sometimes mean that an ambulance has to be diverted from a lower to a higher priority call.
NASMeD are supportive of a letter that was sent to ambulance trusts in April 2019 from Professor , the then National Clinical Director for Urgent and Emergency Care at NHS England to:
“ensure they have robust clinical oversight in place in control rooms to monitor self-harm and suicidal patients safely and effectively, particularly those who have been allocated a Category 3 or 4 response initially”.
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
And stated that:
“consideration should be given, at the point of call, to the type of overdose and quantity taken (where relevant), and to the intent to end life, all of which will determine the necessary response including the need to upgrade a call for clinical reasons...".
A person that is threatening suicide does not constitute a life-threatening emergency and therefore doesn’t warrant a higher category of response but, given the potential for a small number of these cases to become potentially life threatening, early clinical review of these calls is recommended. NASMeD has previously encouraged all ambulance trusts to implement clinical review of these cases in support of the letter sent by Professor in April
2019.
I hope that you will agree that we have responded to the concerns that you have raised. We can assure you that we are absolutely committed to learning from all adverse events in order to prevent them happening again in the future.
If we may be of further assistance, please do not hesitate to contact us.
We would like to extend our sincere condolences to the family of Helen Sheath.
REGULATION 28: HELEN SHEATH
I am writing in response to the Regulation 28 report to prevent future deaths following the inquest into the death of Helen Sheath which you issued on 29th April 2020 to the Association of Ambulance Chief Executives (AACE), National Ambulance Service Medical Directors (NASMeD) and Emergency Call Prioritisation Advisory Group (ECPAG).
AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service however we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. One of our specialist sub groups is the National Ambulance Service Medical Directors (NASMeD) and this response therefore is from AACE and has been informed by NASMeD.
The response categories are set by the Emergency Call Prioritisation Advisory Group (ECPAG), an NHS England led group responsible for the governance, control and approval of any change to clinical code sets (aligning codes to response categories).
When 999 is called, the call is assessed by using a triage tool. East of England Ambulance Service and four other ambulance trusts in England use AMPDS and the other five trusts use NHS pathways. The 999 call taking staff are trained to use these systems and follow a set of questions that relates to the information that is given to them over the telephone and they have to follow a defined process which then determines the category of response. This ensures that all calls are appropriately categorised so that patients with life threatening conditions receive the most appropriate and timely response. This does sometimes mean that an ambulance has to be diverted from a lower to a higher priority call.
NASMeD are supportive of a letter that was sent to ambulance trusts in April 2019 from Professor , the then National Clinical Director for Urgent and Emergency Care at NHS England to:
“ensure they have robust clinical oversight in place in control rooms to monitor self-harm and suicidal patients safely and effectively, particularly those who have been allocated a Category 3 or 4 response initially”.
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
And stated that:
“consideration should be given, at the point of call, to the type of overdose and quantity taken (where relevant), and to the intent to end life, all of which will determine the necessary response including the need to upgrade a call for clinical reasons...".
A person that is threatening suicide does not constitute a life-threatening emergency and therefore doesn’t warrant a higher category of response but, given the potential for a small number of these cases to become potentially life threatening, early clinical review of these calls is recommended. NASMeD has previously encouraged all ambulance trusts to implement clinical review of these cases in support of the letter sent by Professor in April
2019.
I hope that you will agree that we have responded to the concerns that you have raised. We can assure you that we are absolutely committed to learning from all adverse events in order to prevent them happening again in the future.
If we may be of further assistance, please do not hesitate to contact us.
We would like to extend our sincere condolences to the family of Helen Sheath.
Sent To
- Association of Ambulance Chief Executives
- Emergency Call Prioritisation Advisory Group (ECPAG)
- National Association of Ambulance Medical Directors
Response Status
Linked responses
1 of 3
56-Day Deadline
24 Mar 2020
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On Twenty-Eighth July 2019 I commenced an Investigation into the death of Helen Jayne SHEATH aged 33. The investigation concluded at the end of the inquest on Tenth December 2019. The conclusion of the inquest was a Narrative Conclusion :The Deceased died from a fatal dose of sodium nitrate; although this was procured by the Deceased and self-administered, her intentions in doing so were unclear. The medical cause of death was: Ia Fatal Methemoglobinemia Ib Ingestion of Sodium Nitrate II Excess use of Fluoxetine
Circumstances of the Death
The Deceased had a recent history of self-harm and suicidal ideation which had resulted in several in-patient psychiatric admissions. Following her discharge from the last admission in Townsend Court on 3 July 2019 she was still awaiting an Out-Patient Appointment with psychological assessment and treatment from the Community Mental Health Team when, whilst at home, she ingested a fatal dose of sodium nitrate at around 6.30pm on 20 August 2018. Paramedics were first called at 6.20pm and attended to her at 7.05pm; however, soon after their arrival, she became acutely unwell. She was admitted to Bedford Hospital but, despite treatment, her death was confirmed there at 8.25pm. Although the Community Mental Health Team had been alerted to her threats to harm herself and had attended her home earlier that
Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX afternoon they had left before being able to gain access even though a family member was due to attend later with a key. Although their continued presence at the property would not necessarily have avoided the fatal outcome it could potentially have done so.
Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX afternoon they had left before being able to gain access even though a family member was due to attend later with a key. Although their continued presence at the property would not necessarily have avoided the fatal outcome it could potentially have done so.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.