Ashley Walker
PFD Report
All Responded
Ref: 2020-0019
All 1 response received
· Deadline: 27 Mar 2020
Coroner's Concerns (AI summary)
A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
View full coroner's concerns
(1) It is apparent that a communication error confused the ingestion of with a spillage of . (2) toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance.
Responses
Action Taken
Following a communication error, WMAS has instructed all staff to remove the WISER app from work devices unless trained. They have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents. (AI summary)
Following a communication error, WMAS has instructed all staff to remove the WISER app from work devices unless trained. They have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents. (AI summary)
View full response
Dear Mr McGovern
Re: Regulation 28 Report to Prevent Future Deaths - Ashley Walker (Deceased)
Thank you for your email dated 4 February 2020 attaching your Regulation 28 Report.
Please see our response to your concerns below:
Concern 1 It is apparent that a communication error confused the ingestion of sodium nitrate with a spillage of sodium nitrate.
Response Following this incident we have instructed all of our staff to remove the WISER (Wireless Informaton System for Emergency Responders) App from all work mobile phones and tablets. The App will now only be used following training by Tactical Incident Commandars (TICs), the National Inter-Agency Liaison Officer (NILO) and team leaders in our Hazardous Area Response Team (HART). This is to ensure the risk of harm to both our patients and staff is reduced and to mitigate confusion at scene, as crews on scene will only be able to access advice from trained officers.
As a Trust we have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents which highlight the clinical management differences between individual ingestion and chemical spills for all of our Officers.
Concern 2 Sodium nitrate toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance.
Response We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.
Can I please take this opportunity to pass on my sincere condolences to the family of Mr Walker.
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.
Re: Regulation 28 Report to Prevent Future Deaths - Ashley Walker (Deceased)
Thank you for your email dated 4 February 2020 attaching your Regulation 28 Report.
Please see our response to your concerns below:
Concern 1 It is apparent that a communication error confused the ingestion of sodium nitrate with a spillage of sodium nitrate.
Response Following this incident we have instructed all of our staff to remove the WISER (Wireless Informaton System for Emergency Responders) App from all work mobile phones and tablets. The App will now only be used following training by Tactical Incident Commandars (TICs), the National Inter-Agency Liaison Officer (NILO) and team leaders in our Hazardous Area Response Team (HART). This is to ensure the risk of harm to both our patients and staff is reduced and to mitigate confusion at scene, as crews on scene will only be able to access advice from trained officers.
As a Trust we have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents which highlight the clinical management differences between individual ingestion and chemical spills for all of our Officers.
Concern 2 Sodium nitrate toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance.
Response We are currently reviewing whether it would be feasible for our Hazardous Area Response Team (HART) paramedics to carry and administer methylene blue along with other medications to clinically manage cases where there has been chemical ingestion of sodium nitrate. The Lead Paramedic for the Trust has raised this nationally with the National Ambulance Resilience Unit (NARU) clinical sub-group, with a view to making this standard practice nationally.
Can I please take this opportunity to pass on my sincere condolences to the family of Mr Walker.
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.
Sent To
- West Midlands Ambulance Service
Response Status
Linked responses
1 of 1
56-Day Deadline
27 Mar 2020
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 19 August 2019 I commenced an investigation into the death of, Ashley WALKER, 25 years old. The investigation concluded at the end of the inquest on 30 January 2020. The conclusion of the inquest was suicide.
Circumstances of the Death
On 17 August 2019, Mr Walker telephoned West Midland Ambulance Service (WMAS) and informed them he had ingested . An ambulance crew was dispatched to his property and arrived at 1324. On arrival Mr Walker’s Glasgow Coma Score was 3 which increased to 6 after the administration of oxygen. The crew continued to treat Mr Walker until 1345 when they were directed to leave as the scene was said to be hazardous to their health. The scene was not hazardous and there was no requirement for the crew to leave. Mr Walker was left unattended for 45 minutes until the fire crew extricated him from the building. He was not breathing when he was extricated. I heard evidence that he had ‘ a real chance of survival’ had the crew not left.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.