Aston McLean
PFD Report
All Responded
Ref: 2020-0015
All 1 response received
· Deadline: 16 Mar 2020
Coroner's Concerns (AI summary)
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of fire service capabilities for vehicle lifting, hindering decision-making.
View full coroner's concerns
invite you to reconsider your guidelines in relation to ROLE, to clarify that this should only occur where death has already taken place, and not on the basis of either of the following assumptions: (a) Likely death at some imminent point in the future; andlor (b) Perceived difficulty in the timing of extracting a patient from a position where providing treatment is physically impossible In this case, the decision not to lift the vehicle was based on a declaration of death in circumstances where the ambulance crew had no knowledge of how quickly the fire service would be able to lift the vehicle off Aston: Whilst the jury found that this did not cause or contribute to Aston's death, there is a risk of future deaths should a similar scenario occur; (2) The need for a wider category of injuries 'unequivocally associated with death" (i.e. "massive similar injuries makes sense, given that no list could possibly include scenario. The current guidance makes clear that any condition in this category must be 'unequivocally associated with death" In addition, the phrase 'similar massive injuries" is in the same category as "hemicorporectomy" It may be that the inference from this is already sufficiently clear; but it may also be useful for you to consider making clear what level of injury is covered by the phrase "similar massive injuries There should presumably be no doubt whatsoever that death has occurred (3) It was clear from the evidence in this case that the crew attending did not know that the fire service had equipment which would have enabled them to lift the vehicle off Aston within short space of time_ This could clearly form an important part of decision making at scenes like this invite you to consider incorporating within your guidelines the recommendation that local ambulance services should obtain relevant information from their local fire service on this point; and include this in local guidance.
Responses
Action Planned
The Association of Ambulance Chief Executives is reviewing the JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). They will amend the wording to clarify what to do when access to the patient is not possible and to clarify the need to work with other agencies. (AI summary)
The Association of Ambulance Chief Executives is reviewing the JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). They will amend the wording to clarify what to do when access to the patient is not possible and to clarify the need to work with other agencies. (AI summary)
View full response
Dear Mrs Connor
REGULATION 28 REPORT: ACTION TO PREVENT FUTURE DEATHS: ASTON NEIL MCLEAN
We are writing further to your Regulation 28 report to prevent future deaths which you issued following the inquest into the death of Aston Neil McLean, and sent by e mail to JRCALC on 21st January 2020.
Firstly, may we clarify the roles of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the Association of Ambulance Chief Executives (AACE) and the National Ambulance Services Medical Directors group (NASMeD). JRCALC is a group of medical specialty experts and its role is to provide robust expert clinical advice on the instruction of AACE and its advisors, NASMeD. AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts which are all full voting members. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Its primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines.
The responsibility for standards of clinical care within Ambulance Trusts rests with the Chief Executives and Medical Directors of each ambulance service. On behalf of AACE, NASMeD provides clinical assurance and leads the development of future versions of the clinical guidelines.
With regards to your matters of concern, we are reviewing the current JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). We will be amending and adding wording to clarify what to do in circumstances where access to the patient is not possible, such as when trapped under a vehicle or in an inaccessible position. We will be clarifying the need to work with other agencies such as the fire and police services, to support the decisions made with regard to rescue and considering factors such as the safety and risks to the rescue teams. Once these changes have been approved, we will issue them onto the JRCALC App. This is the platform for ambulance clinicians to access the latest and most up to date clinical guidelines.
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
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 and doing everything within our power 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 Aston’s family.
REGULATION 28 REPORT: ACTION TO PREVENT FUTURE DEATHS: ASTON NEIL MCLEAN
We are writing further to your Regulation 28 report to prevent future deaths which you issued following the inquest into the death of Aston Neil McLean, and sent by e mail to JRCALC on 21st January 2020.
Firstly, may we clarify the roles of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the Association of Ambulance Chief Executives (AACE) and the National Ambulance Services Medical Directors group (NASMeD). JRCALC is a group of medical specialty experts and its role is to provide robust expert clinical advice on the instruction of AACE and its advisors, NASMeD. AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts which are all full voting members. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Its primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines.
The responsibility for standards of clinical care within Ambulance Trusts rests with the Chief Executives and Medical Directors of each ambulance service. On behalf of AACE, NASMeD provides clinical assurance and leads the development of future versions of the clinical guidelines.
With regards to your matters of concern, we are reviewing the current JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). We will be amending and adding wording to clarify what to do in circumstances where access to the patient is not possible, such as when trapped under a vehicle or in an inaccessible position. We will be clarifying the need to work with other agencies such as the fire and police services, to support the decisions made with regard to rescue and considering factors such as the safety and risks to the rescue teams. Once these changes have been approved, we will issue them onto the JRCALC App. This is the platform for ambulance clinicians to access the latest and most up to date clinical guidelines.
Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE
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 and doing everything within our power 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 Aston’s family.
Sent To
- JRCALC
Response Status
Linked responses
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56-Day Deadline
16 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
conducted an inquest into the death of Aston Neil McLean that was heard by a jury at Reading Town Hall from 11-22 November 2019. The jury concluded that the timing of the decision by ambulance staff to declare Aston deceased on scene did not cause or contribute to his death.
Circumstances of the Death
The family asked us to refer to the deceased as Aston at the inquest reflected that request in this report: In the early hours of 6 August 2014, Aston was pursued by Thames Police from the scene of a suspected offence. Tragically, this resulted in a collision with an armed response vehicle at 01.56 hours that morning Aston was trapped underneath the vehicle_ An ambulance technician attended at 01.59 hours_ When he got to Aston; he could see his head sticking out from under the vehicle: He was not able to assess Aston's airway: He could not see or hear any breathing He was not able to feel a pulse on Aston's wrist: He was not able to detect any neurological response or signs of life. He concluded that Aston was dead_ Aston was declared deceased at 02.05 hours_ Subsequent to this it was agreed that there was no way to lift the heavy armed response vehicle in a safe manner. The evidence of the ambulance crew was that they did not know how long it would take for the service to attend, nor how long it would take them to lift the vehicle off Aston The ambulance crew who attended believed Aston had injuries incompatible with life_ assumed Aston had been under the vehicle for longer than he in fact had. It was thought that Aston had suffered a injury which was unequivocally associated with death" because of the car crushing down on him: When completing the Recognition of Life Extinct form ('ROLE') , the crew felt that the relevant category was that of "massive similar injuries' Subsequent evidence from the fire service (together with reconstruction videos) indicated that the fire service was likely to have been able to lift the vehicle off Aston within 4%2 minutes_ They were in attendance at the scene from 02.04 instructed an independent expert in this case. He is an ICU consultant who has previously been the Clinical Director of an ambulance service and is also involved in reviewing JRCALC guidelines The expert gave evidence that he too would have declared Aston deceased in the way that the attending crew did. He also however indicated that; if the vehicle had been lifted off Aston soon after the collision, he may_have_survived This_aspect of_his_evidence_is_arquably contradictory__given_that Classification: OFFICIAL-SENSITIVE 'have Valley fire They very
Classification: OFFICIAL-SENSITIVE recognition of life extinct by an ambulance clinician can only take place where there is a condition unequivocally associated with death" It would appear that in this scenario both the attending crew and the expert have taken into account (correctly or otherwise) a view that the vehicle could not be lifted off Aston soon enough to change the outcome:
Classification: OFFICIAL-SENSITIVE recognition of life extinct by an ambulance clinician can only take place where there is a condition unequivocally associated with death" It would appear that in this scenario both the attending crew and the expert have taken into account (correctly or otherwise) a view that the vehicle could not be lifted off Aston soon enough to change the outcome:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe your organisation has the power to take such action:
Copies Sent To
SENSITIVE every key and
Classification: OFFICIAL
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.