Oliver Hall
PFD Report
3 of 3 responses identified
Ref: 2019-0198
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
All 3 listed responses identified
· Deadline: 12 Aug 2019
Coroner's Concerns (AI summary)
Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.
View full coroner's concerns
who, The leg: sopm: and the MATTERS OF CONCERN as follows
1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground. In Oliver's case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a 'severe illness and a rash suggestive of septicaemia' following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver's actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician. In response to their algorithms the NHS 111 Service implemented a disposition of an 'emergency ambulance response for septicaemia' and an automatic referral was made to the 999 service_ This disposition and a 'severe illness and a rash suggestive of septicaemia' were included in the information transferred to the East of England Ambulance Service. However; it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP's) with that information The message made available to the crew simply read 'headachelabdo-pain/fever-no access issues, patient not alone 38.8' Both the ambulance crew and GP's stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the performance times for the category of call. It was identified, that in a septicaemia case similar to Oliver's (or indeed case where time is of essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2_ As such, any medical professional who calls for an ambulance will only be told there will be a if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases): Therefore, under the current system_ a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less_ Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patients condition would have rapidly deteriorated_ As such; under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case) , that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating_ key any the delay
3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee_ This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child. Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as at the top end f the normal range for a six-year-old child The health professionals involved in Oliver's case had relied on this guidance However; in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response_ The health professionals involved in Oliver's case said were either unaware of this guidance, or they were aware of it but placed their reliance on 'normal range' guidance above: Therefore, it is apparent that the significance of Oliver's heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment; to be due to the nature of the conflicting guidance as detailed above.
1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground. In Oliver's case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a 'severe illness and a rash suggestive of septicaemia' following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver's actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician. In response to their algorithms the NHS 111 Service implemented a disposition of an 'emergency ambulance response for septicaemia' and an automatic referral was made to the 999 service_ This disposition and a 'severe illness and a rash suggestive of septicaemia' were included in the information transferred to the East of England Ambulance Service. However; it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP's) with that information The message made available to the crew simply read 'headachelabdo-pain/fever-no access issues, patient not alone 38.8' Both the ambulance crew and GP's stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the performance times for the category of call. It was identified, that in a septicaemia case similar to Oliver's (or indeed case where time is of essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2_ As such, any medical professional who calls for an ambulance will only be told there will be a if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases): Therefore, under the current system_ a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less_ Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patients condition would have rapidly deteriorated_ As such; under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case) , that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating_ key any the delay
3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee_ This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child. Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as at the top end f the normal range for a six-year-old child The health professionals involved in Oliver's case had relied on this guidance However; in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response_ The health professionals involved in Oliver's case said were either unaware of this guidance, or they were aware of it but placed their reliance on 'normal range' guidance above: Therefore, it is apparent that the significance of Oliver's heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment; to be due to the nature of the conflicting guidance as detailed above.
Responses
Action Planned
AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. (AI summary)
AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. (AI summary)
View full response
Dear Mr Parsley,
I write in reply to the concerns you raised with me on 17 June 2019 as Chair of the Association of Ambulance Chief Executives (AACE) through a Regulation 28 PFD report following the inquest of Master Oliver Hall.
Firstly, we would like to offer our condolences to the family and those affected by this tragic passing.
To clarify, 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 services 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.
I will address your three key concerns in the order given:
1) It is apparent that there is a failure in the process of the transfer information regarding a patient’s original disposition by the NHS 111 Service to the ambulance service and treating clinicians on the ground....It was then identified that the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with relevant information.
The failure to transfer the most relevant information in this instance is very regrettable. English ambulance services use a number of different Computer Aided Dispatch (CAD) systems and one of two authorised triage platforms to assist them in handling emergency calls effectively. From the narrative report of the inquest, it is clear that information was originally given to the ambulance control room by the NHS 111 service that was not then fully shared with the ambulance resource deployed.
Our Ref: ACM/MF/KAF
Date: 11 August 2019
Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Having consulted with our National Heads of Control Services Group, it is apparent that the process of sharing this information is necessarily selective. This is partly to avoid overburdening clinicians/responders with excessive or non-relevant information and partly because the mobile data terminals in responding resources (ambulances or cars) have limits on what can be displayed. The systems used vary across the country and the exact nature of what is displayed in the vehicle is determined by the individual ambulance service within the limits of the technology it utilises. We understand that East of England Ambulance Service has reviewed their local processes to take on board your concerns.
Although the process and systems are well established, improvements can always be made. I am pleased to inform you that during 2020/21 elements of the new National Emergency Services Mobile Communication Programme will be implemented across all ambulance services and this will include a greater ability to manage information through the new National Mobilisation Platform. This may in turn allow us to further standardise the types of information displayed on the mobile data terminals in ambulance vehicles.
2) Your concern regarding medical professionals being able to make an informed decision with regard to possible delays in ambulance attendance and that under the current system (highlighted in this case) a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less
Work has been ongoing over the last two years to improve the handling of emergency calls received from Health Care Professionals (HCP). NHS England have now published the National Framework for Healthcare Professional Ambulance Responses which clarifies the new roles and processes. The section reprinted below is pertinent in this instance
HCP Level 2 (HCP 2) Category 2 (18 Minute mean response time)
This level of response is based on the clinical condition of the patient and their need for immediate additional clinical care in hospital in an emergency department or acute receiving unit (i.e. medical or surgical assessment unit, delivery suite).
Patients with a National Early Warning Score (NEWS2) of 7 or greater may trigger a request for this level of response, as may the opinion of a HCP who has assessed the patient.
Patients with a NEWS2 of 6 or less may be suitable for an HCP Level 2 response by exception only and HCPs, where possible, should detail the clinical reason. Examples in this category may be patients with sepsis, myocardial infarction, CVA, acute abdomen, acute ischaemic limb, acute pancreatitis, major gastrointestinal haemorrhage and overdose requiring immediate treatment.
Whilst these calls may be flagged within the Trust CAD system as being from a HCP (for AQI reporting purposes), they must be presented and displayed in the Trust CAD system in the same way as Category 2 calls from the public and responded to accordingly.
In essence, it is the patient’s condition that determines the prioritisation of response so that a call from an HCP will receive the same level of response as that of a public 999 call – driven by the clinical condition of the patient.
Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call taker to give accurate information regarding the expected time of arrival of a response. This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for a responding ambulance to be diverted from one emergency to another that has been assessed as more urgent or indeed for a responding ambulance to be flagged down at another incident they may be passing. For these reasons, call takers do not commit to an estimated time of arrival, rather they are asked to say ‘help is on its way and please ring back if the patient’s condition changes’.
3) A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year.
Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be influential on its own. The attending ambulance staff have been taught that the assessment of the child with regard to severity of illness and possible causes would be influenced by a range of observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only by doing this that information received can be verified and form part of subsequent decision making.
Ambulance services are all supportive of the clinical guidelines used across the UK and developed by JRCALC but are fully cognisant that these are guidelines for interpretation as are those published by other organisations.
Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff.
I trust you feel that I have answered your concerns fully and thank you for bringing them to my attention.
I write in reply to the concerns you raised with me on 17 June 2019 as Chair of the Association of Ambulance Chief Executives (AACE) through a Regulation 28 PFD report following the inquest of Master Oliver Hall.
Firstly, we would like to offer our condolences to the family and those affected by this tragic passing.
To clarify, 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 services 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.
I will address your three key concerns in the order given:
1) It is apparent that there is a failure in the process of the transfer information regarding a patient’s original disposition by the NHS 111 Service to the ambulance service and treating clinicians on the ground....It was then identified that the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with relevant information.
The failure to transfer the most relevant information in this instance is very regrettable. English ambulance services use a number of different Computer Aided Dispatch (CAD) systems and one of two authorised triage platforms to assist them in handling emergency calls effectively. From the narrative report of the inquest, it is clear that information was originally given to the ambulance control room by the NHS 111 service that was not then fully shared with the ambulance resource deployed.
Our Ref: ACM/MF/KAF
Date: 11 August 2019
Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Having consulted with our National Heads of Control Services Group, it is apparent that the process of sharing this information is necessarily selective. This is partly to avoid overburdening clinicians/responders with excessive or non-relevant information and partly because the mobile data terminals in responding resources (ambulances or cars) have limits on what can be displayed. The systems used vary across the country and the exact nature of what is displayed in the vehicle is determined by the individual ambulance service within the limits of the technology it utilises. We understand that East of England Ambulance Service has reviewed their local processes to take on board your concerns.
Although the process and systems are well established, improvements can always be made. I am pleased to inform you that during 2020/21 elements of the new National Emergency Services Mobile Communication Programme will be implemented across all ambulance services and this will include a greater ability to manage information through the new National Mobilisation Platform. This may in turn allow us to further standardise the types of information displayed on the mobile data terminals in ambulance vehicles.
2) Your concern regarding medical professionals being able to make an informed decision with regard to possible delays in ambulance attendance and that under the current system (highlighted in this case) a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less
Work has been ongoing over the last two years to improve the handling of emergency calls received from Health Care Professionals (HCP). NHS England have now published the National Framework for Healthcare Professional Ambulance Responses which clarifies the new roles and processes. The section reprinted below is pertinent in this instance
HCP Level 2 (HCP 2) Category 2 (18 Minute mean response time)
This level of response is based on the clinical condition of the patient and their need for immediate additional clinical care in hospital in an emergency department or acute receiving unit (i.e. medical or surgical assessment unit, delivery suite).
Patients with a National Early Warning Score (NEWS2) of 7 or greater may trigger a request for this level of response, as may the opinion of a HCP who has assessed the patient.
Patients with a NEWS2 of 6 or less may be suitable for an HCP Level 2 response by exception only and HCPs, where possible, should detail the clinical reason. Examples in this category may be patients with sepsis, myocardial infarction, CVA, acute abdomen, acute ischaemic limb, acute pancreatitis, major gastrointestinal haemorrhage and overdose requiring immediate treatment.
Whilst these calls may be flagged within the Trust CAD system as being from a HCP (for AQI reporting purposes), they must be presented and displayed in the Trust CAD system in the same way as Category 2 calls from the public and responded to accordingly.
In essence, it is the patient’s condition that determines the prioritisation of response so that a call from an HCP will receive the same level of response as that of a public 999 call – driven by the clinical condition of the patient.
Association of Ambulance Chief Executives Managing Director: Martin Flaherty OBE Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Whether an ambulance is called by the public or an HCP, it is extremely difficult for a call taker to give accurate information regarding the expected time of arrival of a response. This is due to the fluid and ever-changing nature of emergencies. It is not uncommon for a responding ambulance to be diverted from one emergency to another that has been assessed as more urgent or indeed for a responding ambulance to be flagged down at another incident they may be passing. For these reasons, call takers do not commit to an estimated time of arrival, rather they are asked to say ‘help is on its way and please ring back if the patient’s condition changes’.
3) A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year.
Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be influential on its own. The attending ambulance staff have been taught that the assessment of the child with regard to severity of illness and possible causes would be influenced by a range of observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only by doing this that information received can be verified and form part of subsequent decision making.
Ambulance services are all supportive of the clinical guidelines used across the UK and developed by JRCALC but are fully cognisant that these are guidelines for interpretation as are those published by other organisations.
Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff.
I trust you feel that I have answered your concerns fully and thank you for bringing them to my attention.
Action Taken
NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). (AI summary)
NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). (AI summary)
View full response
Dear Mr Parsley, write in response to your letter dated 17 June 2019, regarding the death of Oliver Hall We have considered the circumstances surrounding Oliver's death and the concerns raised in your report. In particular; the concerns raised regarding the NICE guidance on treatment of sepsis and perceived lack of clarity over the heart rate which should trigger a medical treatment response in an unwell 6 year old child. We consider that the NICE guideline on sepsis: recognition_diagnosis andearly management (NG51 is a relevant is a relevant reference in this case Of particular relevance is recommendation 1.4.5 in the guideline, which says:
1.4.5 Recognise that children aged 5-11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis: has objective evidence of altered behaviour or mental state, or appears ill to a healthcare professional, or does not wake (or if roused, does not stay awake) respiratory rate: aged 5 years, 29 breaths per minute or more aged 6-7 years, 27 breaths per minute or more aged 8-11 years, 25 breaths per minute or more oxygen saturation of less than 90% in air or increased oxygen requirement over baseline heart rate: aged 5 years, 130 beats per minute or more
6-7 years, 120 beats per minute or more 8-11 years, 115 beats per minute or more or heart rate less than 60 beats per minute at any age mottled or ashen appearance cyanosis of the skin, lips or tongue non-blanching rash of the skin. This is also set out in table 2, which is titled 'Risk stratification tool for children 5-11 years with suspected sepsis' . 2 heart rates mentioned in your report are 137 bpm and 120 bpm, both of which should have prompted clinicians involved to refer to recommendation 1.5.1 of the guideline, which says:
1.5.1 Refer all people with suspected sepsis outside acute hospital settings for emergency medical by the most appropriate means of transport (usually 999 ambulance) if: meet any high risk criteria (see tables 1, 2 and 3) or are aged under 17 years and their immunity is impaired by drugs or illness and have any moderate to high risk criteria_ [1} Emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit. In addition to NICE guidance, our website provides access to Clinical Knowledge Summaries (CKS) which set out the current evidence base and best practice on more than 360 common and significant primary care presentations These summaries are commissioned by NICE, but they are not formal NICE guidelines. are authored by an external contractor using a development process that has been accredited by NICE: Information in the CKS Meningitis topic has now been reviewed and amended to ensure this topic is consistent with information in the NICE guideline sepsis: recognition, diagnosis and early management (NG51): An improved process for sharing information about new and updated NICE guidelines that impact primary care is being developed. This process will also provide the contractors with more focussed and current information on future NICE releases than is currently available and will ensure CKS topics can be scheduled for review and updated in as timely a manner as possible.
1.4.5 Recognise that children aged 5-11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis: has objective evidence of altered behaviour or mental state, or appears ill to a healthcare professional, or does not wake (or if roused, does not stay awake) respiratory rate: aged 5 years, 29 breaths per minute or more aged 6-7 years, 27 breaths per minute or more aged 8-11 years, 25 breaths per minute or more oxygen saturation of less than 90% in air or increased oxygen requirement over baseline heart rate: aged 5 years, 130 beats per minute or more
6-7 years, 120 beats per minute or more 8-11 years, 115 beats per minute or more or heart rate less than 60 beats per minute at any age mottled or ashen appearance cyanosis of the skin, lips or tongue non-blanching rash of the skin. This is also set out in table 2, which is titled 'Risk stratification tool for children 5-11 years with suspected sepsis' . 2 heart rates mentioned in your report are 137 bpm and 120 bpm, both of which should have prompted clinicians involved to refer to recommendation 1.5.1 of the guideline, which says:
1.5.1 Refer all people with suspected sepsis outside acute hospital settings for emergency medical by the most appropriate means of transport (usually 999 ambulance) if: meet any high risk criteria (see tables 1, 2 and 3) or are aged under 17 years and their immunity is impaired by drugs or illness and have any moderate to high risk criteria_ [1} Emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit. In addition to NICE guidance, our website provides access to Clinical Knowledge Summaries (CKS) which set out the current evidence base and best practice on more than 360 common and significant primary care presentations These summaries are commissioned by NICE, but they are not formal NICE guidelines. are authored by an external contractor using a development process that has been accredited by NICE: Information in the CKS Meningitis topic has now been reviewed and amended to ensure this topic is consistent with information in the NICE guideline sepsis: recognition, diagnosis and early management (NG51): An improved process for sharing information about new and updated NICE guidelines that impact primary care is being developed. This process will also provide the contractors with more focussed and current information on future NICE releases than is currently available and will ensure CKS topics can be scheduled for review and updated in as timely a manner as possible.
Action Planned
EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission. (AI summary)
EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission. (AI summary)
View full response
Dear Mr Parsley, Re: Regulation 28 Oliver Hall (17th June 2019) am writing to you following the inquest of Mr Oliver Hall and the Trusts receipt of a Regulation 28. In order to address your concerns, as outlined in Section 5, will outline the Trusts current position and areas which are being considered for changelbeing changed. Process of the transfer of information regarding patient's original disposition by the NHS 111 service to the Ambulance service and the treating clinicians; the current East of England Ambulance service system does not provide the ambulance crew (and therefore in this case subsequently the GP's) with relevant information: The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system , some of which also use the same triage system (Pathways) as UK 111 providers The initial stage of this consultation is to share best practice and solutions with regards to how information is recorded and subsequently transmitted to attending resources using existing technology: Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff;, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways. The current system will not identify to medical professional delay which is outside (just under) the category for that call, for example a call is made by a medical professional requesting an ambulance and one is not immediately available will be informed of an anticipated response time outside of the performance times for that category of call; For C2 the medical professional will only be told if the anticipated delay will be 40 minutes or longer: As heard in evidence at the inquest communication had been sent to stakeholders, including lhe cinical Commissioning Groups, regarding the Ambulance Response Program (ARP) call categories in September 2018_ However, he was unable to find evidence that GP's in the region had received further communication regarding how these new categories related to 999 calls made by Health Care professionals_ Interim Chief Executive; Dorothy Hosein Chair: Nigel Beverly WWWeastamb nhs_uk the they key key
The Trust; along with all UK Ambulance Trusts, will shortly be implementing the National Framework for Healthcare Professional Ambulance Responses. The aim of this framework is to standardise nationally how calls from HCPs are {riaged and responded to in line with the ARP call categories and to identify those palients who require immediate clinical intervention as well as transportation. Further information can be found at: https ILwwwengland nhs uklpublication/healthcare-professional-ambulance-responses-frameworkl The Trust currently is aiming to implement this framework on 24"h September 2019 and as part of this implementation stakeholders , such as Clinical Commissioning Groups and Health Care Professionals (HCP) across the region, will receive updated and comprehensive guidance including the call categories associated with HCP calls A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college's ambulance Iiaison committee , specifically in matters of the pulse rate of 120 in a six year_ The National Institute for Health and Care Excellence (NICE) has guideline NG51 ~'Sepsis: recognition, diagnosis and early management' This guidance was published in July 2016 and updated September
2017. NICE formally recognise and endorse the work and decision support tools of the UK Sepsis Trust When reviewing the UK Sepsis Trust 'Sepsis screening tool prehospital (age 5-11)', red flag sepsis is considered if there is a severe tachycardia_ The screening tool goes onto define a severe tachycardia as a heart rate greater than or equal to 120 beats per minute for children aged six to seven years of age: This is further reinforced on the NICE 'Sepsis risk stratification tool: children aged 5-11 years out of hospital'_ Guidance issued by NICE provides clarity surrounding the recognition and identification of high risk criteria in Sepsis_ For any patient presenting with high risk sepsis the patient should be urgently seen in an emergency care setting with resuscitation facilities_ NICE states that for children aged 5-11 years, low and moderate to high risk criteria could be treated in an of hospital setting if the condition can be definitively diagnosed and treated. The UK Ambulance Services Clinical Practice Guidelines 2016 (JRCALC) identify that six-year-old child would be expected to have a heart rate of 80-120 beats per minute. In the 2016 guidelines, sepsis in children is covered in a section pertaining to febrile illness in children and the guidance not greatly developed_ A new 2018 update has just been launched, within this is update there is greater depth of information that; whilst formatted in a different way does broadly align to NICE guidance. EEAST has, for a number of years followed and endorsed the work of UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our 'Clinical Manual' an electronic resource available to staff that is designed to augmenf the guidance offered by JRCALC Kind regards, Dorothy Hosein Interim Chief Executive Interim Chief Executive; Dorothy Hosein Chair: Nigel Beverly WWW eastambnhs uk the key out the
The Trust; along with all UK Ambulance Trusts, will shortly be implementing the National Framework for Healthcare Professional Ambulance Responses. The aim of this framework is to standardise nationally how calls from HCPs are {riaged and responded to in line with the ARP call categories and to identify those palients who require immediate clinical intervention as well as transportation. Further information can be found at: https ILwwwengland nhs uklpublication/healthcare-professional-ambulance-responses-frameworkl The Trust currently is aiming to implement this framework on 24"h September 2019 and as part of this implementation stakeholders , such as Clinical Commissioning Groups and Health Care Professionals (HCP) across the region, will receive updated and comprehensive guidance including the call categories associated with HCP calls A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college's ambulance Iiaison committee , specifically in matters of the pulse rate of 120 in a six year_ The National Institute for Health and Care Excellence (NICE) has guideline NG51 ~'Sepsis: recognition, diagnosis and early management' This guidance was published in July 2016 and updated September
2017. NICE formally recognise and endorse the work and decision support tools of the UK Sepsis Trust When reviewing the UK Sepsis Trust 'Sepsis screening tool prehospital (age 5-11)', red flag sepsis is considered if there is a severe tachycardia_ The screening tool goes onto define a severe tachycardia as a heart rate greater than or equal to 120 beats per minute for children aged six to seven years of age: This is further reinforced on the NICE 'Sepsis risk stratification tool: children aged 5-11 years out of hospital'_ Guidance issued by NICE provides clarity surrounding the recognition and identification of high risk criteria in Sepsis_ For any patient presenting with high risk sepsis the patient should be urgently seen in an emergency care setting with resuscitation facilities_ NICE states that for children aged 5-11 years, low and moderate to high risk criteria could be treated in an of hospital setting if the condition can be definitively diagnosed and treated. The UK Ambulance Services Clinical Practice Guidelines 2016 (JRCALC) identify that six-year-old child would be expected to have a heart rate of 80-120 beats per minute. In the 2016 guidelines, sepsis in children is covered in a section pertaining to febrile illness in children and the guidance not greatly developed_ A new 2018 update has just been launched, within this is update there is greater depth of information that; whilst formatted in a different way does broadly align to NICE guidance. EEAST has, for a number of years followed and endorsed the work of UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our 'Clinical Manual' an electronic resource available to staff that is designed to augmenf the guidance offered by JRCALC Kind regards, Dorothy Hosein Interim Chief Executive Interim Chief Executive; Dorothy Hosein Chair: Nigel Beverly WWW eastambnhs uk the key out the
Sent To
- Association of Ambulance
- East of England Ambulance Service
- N.I.C.E
Responses Identified
Responses identified
3 of 3
56-Day Deadline
12 Aug 2019
All listed responses identified
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 Ist August 2016 | commenced an investigation into the death of Oliver Hall The investigation concluded at the end of the inquest on 7th June 2019. The conclusion of the inquest was that the death was the result of:- Natural causes contributed to by neglect The medical cause of death was confirmed as: 1(a) Meningococcal septicaemia
Circumstances of the Death
Oliver Hall was a six-year old who died suddenly on the 24th Oct 2017 after becoming acutely unwell on the 23rd October 2017. At the time of his death Oliver had been admitted to the James Paget University Hospital, Gorleston, Norfolk, although he resided in Haverhill, Suffolk. Way boy
Oliver became unwell on the morning of 23rd October 2017 when he became lethargic, photophobic, had a sore neck; a temperature which was resistant to Calpol and Calprofen and had developed a rash which his mother felt was non-blanching called her GP just before 1Oam and requested an appointment; emphasising that her child was unwell with a temperature which was not responding to medication She was advised the earliest appointment was at 3.5Opm that afternoon but she was to call back if there was any change in circumstances Following a further call to the GP practice, contacted the NHS 111 number on hearing of Oliver's symptoms; sent an ambulance The NHS Pathway System recorded a disposition for the call relating to Oliver as 'emergency ambulance response for septicaemia' The ambulance crew arrived at around Ipm. Idescribed her son's symptoms as outlined above. She told them she was concerned that her son had meningitis. The ambulance crew completed a full set of observations (excluding blood pressure): Upon arrival Oliver's pulse rate was 137 bpm and after approximately 15 minutes this settled to 120 bpm: The ambulance crew said that Oliver did not have meningitis because his rash disappeared under pressure_ Oliver's mother said the edges of the rash blanched and they were in effect only partially blanching: Oliver also had one purple raised area on his arm that did not blanch which the crew thought may have been from the result of trauma ambulance crew said Oliver didn't need to go to hospital but agreed to take him to his GP such was anxiety as to her son's condition. They arrived at the GP practice at around 2.3Opm. Initially a trainee GP saw Oliver in the presence of his mother and both of the ambulance crew: Again; mentioned her concerns regarding meningitis with the GP taking the history from the paramedics. The trainee GP took Oliver's temperature but did not record any of Oliver's other vital signs, accepting these were normal from the ambulance crew: Upon seeing the non-blanching purple mark on Oliver's forearm the trainee GP interrupted his examination to seek assistance from his training supervisor. Both doctors returned but a physical top to toe examination was not completed The mark on Oliver's arm was assessed by the second GP who also briefly looked at a maculopapular rash on his A group decision by the four medical personnel present was made that Oliver was well enough to go home. Almost one hour had passed since Oliver's vital signs had been taken That evening; Oliver's spots were getting worse. Idecided to take her son back to the GP who recognised a meningococcal non-blanching rash at 6.45pm. The GP immediately gave Oliver an injection of antibiotics and called 999 for an ambulance at 6_ After a thirty minute wait the GP called 999 again was told there was 'no resource available'_ decided not to wait and she and her husband drove Oliver straight to hospital, arriving at the James Paget University Hospital at around 8pm. Tragically, despite the best efforts of the medical staff at the hospital, Oliver passed away in the early hours Of 24h October 2017.
Oliver became unwell on the morning of 23rd October 2017 when he became lethargic, photophobic, had a sore neck; a temperature which was resistant to Calpol and Calprofen and had developed a rash which his mother felt was non-blanching called her GP just before 1Oam and requested an appointment; emphasising that her child was unwell with a temperature which was not responding to medication She was advised the earliest appointment was at 3.5Opm that afternoon but she was to call back if there was any change in circumstances Following a further call to the GP practice, contacted the NHS 111 number on hearing of Oliver's symptoms; sent an ambulance The NHS Pathway System recorded a disposition for the call relating to Oliver as 'emergency ambulance response for septicaemia' The ambulance crew arrived at around Ipm. Idescribed her son's symptoms as outlined above. She told them she was concerned that her son had meningitis. The ambulance crew completed a full set of observations (excluding blood pressure): Upon arrival Oliver's pulse rate was 137 bpm and after approximately 15 minutes this settled to 120 bpm: The ambulance crew said that Oliver did not have meningitis because his rash disappeared under pressure_ Oliver's mother said the edges of the rash blanched and they were in effect only partially blanching: Oliver also had one purple raised area on his arm that did not blanch which the crew thought may have been from the result of trauma ambulance crew said Oliver didn't need to go to hospital but agreed to take him to his GP such was anxiety as to her son's condition. They arrived at the GP practice at around 2.3Opm. Initially a trainee GP saw Oliver in the presence of his mother and both of the ambulance crew: Again; mentioned her concerns regarding meningitis with the GP taking the history from the paramedics. The trainee GP took Oliver's temperature but did not record any of Oliver's other vital signs, accepting these were normal from the ambulance crew: Upon seeing the non-blanching purple mark on Oliver's forearm the trainee GP interrupted his examination to seek assistance from his training supervisor. Both doctors returned but a physical top to toe examination was not completed The mark on Oliver's arm was assessed by the second GP who also briefly looked at a maculopapular rash on his A group decision by the four medical personnel present was made that Oliver was well enough to go home. Almost one hour had passed since Oliver's vital signs had been taken That evening; Oliver's spots were getting worse. Idecided to take her son back to the GP who recognised a meningococcal non-blanching rash at 6.45pm. The GP immediately gave Oliver an injection of antibiotics and called 999 for an ambulance at 6_ After a thirty minute wait the GP called 999 again was told there was 'no resource available'_ decided not to wait and she and her husband drove Oliver straight to hospital, arriving at the James Paget University Hospital at around 8pm. Tragically, despite the best efforts of the medical staff at the hospital, Oliver passed away in the early hours Of 24h October 2017.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.