Margaret Stemp
PFD Report
All Responded
Ref: 2018-0198
All 1 response received
· Deadline: 13 Aug 2018
Coroner's Concerns (AI summary)
Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate worsening conditions.
View full coroner's concerns
(1) That there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours and what would have been considerably longer had the Police not attended.
(2) That the Police had to be used to provide the necessary welfare support to these ladies (3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance.
(4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend.
(2) That the Police had to be used to provide the necessary welfare support to these ladies (3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance.
(4) That there was no clinical oversight of the decision to stand the Ambulance down despite knowing i) the age of these two ladies ii) the fact that they were vulnerable iii) that they had fallen and iv) that the Police (who had seen the two ladies) had indicated that the Ambulance Service should still attend.
Responses
Action Taken
South East Coast Ambulance Service NHS Trust is recruiting additional crew members and purchasing new and second-hand ambulances. They have provided enhanced training to Support Call Takers, introduced a new Patient Welfare Procedure, and changed the procedure for standing down ambulances. (AI summary)
South East Coast Ambulance Service NHS Trust is recruiting additional crew members and purchasing new and second-hand ambulances. They have provided enhanced training to Support Call Takers, introduced a new Patient Welfare Procedure, and changed the procedure for standing down ambulances. (AI summary)
View full response
Dear Madam write to respond to the Regulation 28 Report you issued on 25 June 2018 following the inquest into the death of Margaret Stemp. was very sorry to hear of Mrs Stemp's death, and that we were not able to provide the response that we aspire to when her sister called for help on Christmas
2017. would Iike to address in turn each of the areas of concern that you have raised: 1 . There were insufficient resources_to_deal with _the_high number of_calls on the dayin question The Christmas period, and specifically Christmas is one of the busiest and most challenging times of the year for the ambulance service. We anticipate increased demand and roster increased resources to try to meet that anticipated demand. On Christmas 2017, the level of demand was even greater than we had anticipated and for which we had resourced_ At times of highest demand, priority is given to patients in an immediately life threatening position. In order to avoid this situation recurring in future periods of very high demand, we have taken the following action:
a. We are aiming to recruit an additional 300 ambulance crew members, sO we have more resources that we can call upon for times of maximum demand_ b We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have Chairman: Graham Colbert (Interim) Chief Executive: Daren Mochrie QAM Your Service, jour call Day Day, Day will
purchased 30 second hand ambulances so far this year; to help us to deal with anticipated winter pressures We are, together with our commissioners , carrying out "Demand and Capacity Revlew' which will enable both parties to determine: the resources needed to meet the demand on our service, to cope with increased pressure throughout the acute healthcare system, including "out of hours provision, and how those resources will be provided. d_ We have planned review of our forecasting model, with the objective of better anticipating what resources will be needed for any hour of any making provision for system pressures_ 2 ThePolice_had to_be_used to provide_the necessary welfare support to Mrs Stemp and her sister am grateful to the Police for their assistance on this occasion, however fully accept that the welfare of patients is SECAmb's responsibility, not that of the Police. Since this incident; we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in timely manner: attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while are awaiting an ambulance_ 3 The_call takers_did_not_seem _to_appreciate_the_worsening_condition_of_these_two ladies during the time_they were seeking assistance As a result of this incident; all Support Call Takers have received, and new SCT's will receive on induction, enhanced training with an emphasis on how to recognise worsening of patient's condition and what action to take on recognising that fact: We have introduced a new Patient Welfare Procedure, which involves SCT's working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queuelwaiting calls and help manage them more efficiently from clinical perspective. In addition, system of audit of SCTs' work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring: 4_ There_was no clinical oversight of_the decision to stand the ambulance down As a result of this incident; the procedure for standing down an ambulance has now been changed. Support Call Taker can no longer stand down an ambulance_ A two-step verification process has been introduced whereby must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down: trust that this letter reassures you that we have taken seriously the issues arising from Mrs Stemp's incident on 25 December 2017 and that we have put measures in place to ensure that the situation will not recur. day, they they very
2017. would Iike to address in turn each of the areas of concern that you have raised: 1 . There were insufficient resources_to_deal with _the_high number of_calls on the dayin question The Christmas period, and specifically Christmas is one of the busiest and most challenging times of the year for the ambulance service. We anticipate increased demand and roster increased resources to try to meet that anticipated demand. On Christmas 2017, the level of demand was even greater than we had anticipated and for which we had resourced_ At times of highest demand, priority is given to patients in an immediately life threatening position. In order to avoid this situation recurring in future periods of very high demand, we have taken the following action:
a. We are aiming to recruit an additional 300 ambulance crew members, sO we have more resources that we can call upon for times of maximum demand_ b We are purchasing approximately 100 new ambulances over the course of the next three years, again to increase our resource base. As an immediate measure, we have Chairman: Graham Colbert (Interim) Chief Executive: Daren Mochrie QAM Your Service, jour call Day Day, Day will
purchased 30 second hand ambulances so far this year; to help us to deal with anticipated winter pressures We are, together with our commissioners , carrying out "Demand and Capacity Revlew' which will enable both parties to determine: the resources needed to meet the demand on our service, to cope with increased pressure throughout the acute healthcare system, including "out of hours provision, and how those resources will be provided. d_ We have planned review of our forecasting model, with the objective of better anticipating what resources will be needed for any hour of any making provision for system pressures_ 2 ThePolice_had to_be_used to provide_the necessary welfare support to Mrs Stemp and her sister am grateful to the Police for their assistance on this occasion, however fully accept that the welfare of patients is SECAmb's responsibility, not that of the Police. Since this incident; we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in timely manner: attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while are awaiting an ambulance_ 3 The_call takers_did_not_seem _to_appreciate_the_worsening_condition_of_these_two ladies during the time_they were seeking assistance As a result of this incident; all Support Call Takers have received, and new SCT's will receive on induction, enhanced training with an emphasis on how to recognise worsening of patient's condition and what action to take on recognising that fact: We have introduced a new Patient Welfare Procedure, which involves SCT's working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queuelwaiting calls and help manage them more efficiently from clinical perspective. In addition, system of audit of SCTs' work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring: 4_ There_was no clinical oversight of_the decision to stand the ambulance down As a result of this incident; the procedure for standing down an ambulance has now been changed. Support Call Taker can no longer stand down an ambulance_ A two-step verification process has been introduced whereby must refer the case to a Dispatch Team Leader or Clinician (Clinical Navigator) for the ambulance to be stood down: trust that this letter reassures you that we have taken seriously the issues arising from Mrs Stemp's incident on 25 December 2017 and that we have put measures in place to ensure that the situation will not recur. day, they they very
Sent To
- South East Coast Ambulance Services
Response Status
Linked responses
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56-Day Deadline
13 Aug 2018
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 16th January 2018 I commenced an investigation into the death of MARGARET STEMP, aged 91. The investigation concluded at the end of the inquest on 11th June 2018. The conclusion of the inquest was that “Margaret died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention.”
Circumstances of the Death
During Christmas 2017 Margaret was staying with her sister who was 97 years old. It appears that around 4.00pm on 27th December both sisters had fallen over and were unable to get up. As a result Margaret’s sister contacted the emergency services and an Ambulance was requested. The Ambulance service was under extreme pressure that day and were unable to send an Ambulance to assist these ladies. As the Ambulance service had not arrived after 7 hours the Police attended and assisted the two ladies and got them off the floor. The Police however indicted to the Ambulance service that they should still attend to check over these two ladies. Despite this at 2.00 am the following morning the Ambulance service, who has still not attended, made a further welfare telephone call to the address. They spoke to Margaret’s 97 year old sister. She advised the Ambulance service that she had been waiting for the Ambulance service for a considerable period of time since and she was now going to bed and no longer needed them. The Ambulance Service closed the call without any clinical oversight of that decision. On 28th December a carer attended the sisters’ address. When she arrived she discovered both ladies again on the floor. Sadly Margaret was found deceased and her sister needed to be taken to hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.