UK Inquiry Tracker

Harry Gill

PFD Report All Responded Ref: 2016-0323

Date of Report 30 August 2016

Coroner Michael Singleton

Coroner Area Blackburn, Hyndburn and Ribble Valley

Response Deadline est. 25 October 2016

Community health care and emergency services related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 25 Oct 2016

Coroner's Concerns (AI summary)

The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.

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as follows: That on four of telephone conversations between Mr Gill and his wife and NHS 111 only one call elicited the appropriate response: It would therefore appear that the vomiting pathways is not sufficiently robust to ensure an appropriate response.

Responses

NHS England NHS / Health Body

11 Oct 2016

Action Taken
NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the site training package for managing vomiting. (AI summary)

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Dear Mr Singleton am writing in response to a Section 28 ruling from HM Senior Coroner: This follows the tragic death of Harry Gill who passed away on the Znd June 2016. This was followed by an investigation and inquest which concluded on 24/8/2016. am writing in my role as the Clinical Director for NHS Pathways which is the clinical triage platform for the national NHS 111 service. ami BA, MSc, MB ChB (Sheffield). The Coroner has requested that NHS Pathways review its management of the vomiting pathways and report on any improvements that have been made To aid this process NHS Pathways entered into discussions with the Clinical and Quality Lead for the North Western Ambulance Service (NWAS) to better understand their concerns regarding the structure of the vomiting questions. We agreed there was scope t0 enhance our content and commenced a review with our clinical team This review has now concluded and can report the following changes to the vomiting questions with rationale CURRENT QUESTION The current question presented to the call handler and then asked of the patient is; 'Have you vomited blood or faeces? Call handlers at NWAS reported a degree of confusion with the question and not enough supporting information if the patient answered positively. At present call handlers may ask the question as it appears without making full use of existing supporting information to probe directly about coffee ground vomiting, and a caller may not realise that coffee ground vomit is blood Information and technology WWWdigital nhs.uk fo better heait and care enquiries@nhsdigital nhs.uk

NHS] Digital PRQPOSED CHANGES We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate localised gastric bleed. The question that will be asked in the next release of the algorithms will be; Have you vomited any of the following? A1- Coffee ground vomit Supporting information presented to the call handler; This means the individual has brought up or vomited dark brown or black material that looks like soil or coffee-grounds. Blood that has been in the stomach often looks like this A2-Blood Supporting information presented to the call handler; This means any blood visible in vomit_ This also means any blood in or near the mouth: The blood may have been forcefully vomited up or just be oozing or welling from the mouth. A3- Faeces Supporting information presented to the call handler; This means vomit that looks and smells strongly of faeces (poo): This work has been concluded and will be issued to all NHS Pathways sites for the next release in the spring of next year: In addition we have further enhanced our site training package for the management of vomiting in recognition of the difficulties in identifying the nature of vomit remotely via third party telephone triage. am happy to answer any further enquiries from HM Coroner.

Sent To

NHS Digital

Response Status

Linked responses 1 of 1

56-Day Deadline 25 Oct 2016

All responses received

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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 the 6th of June 2016 I commenced an investigation into the death of Stuart Gill aged 72 years: The investigation concluded at the end of the Inquest which was concluded on the 24th of August 2016. The conclusion of the Inquest was that Harry Gill died from a heart attack brought on by the effects of vomiting caused by an intermittent blockage in his bowel; His death could probably have been prevented but for the failure to appropriately assess his medical condition.

Circumstances of the Death

Harry Gill became unwell and started to vomit on Saturday 28* 2016. He was unable to tolerate food and was trying to take regular sips of water. At 09:S6hrs on Wednesday 1st June 2016 Gill on behalf of her husband contacted NHS 111, The health advisor triaged the call using the vomiting pathway which should have led to a Green response but was incorrectly processed. Arrangements were however made for a clinician to call back some two hours later: clinician should have reached Green 2 response but the triage was incorrectly processed: That call was concluded with advice that should the symptoms get worse or the condition change to ring back NHS 111. At 18.28hrs on Thursday 2nd June 2016 a further call was made to NHS 111 at which time health assistant incorrectly processed the call and although Green response should have been reached instead arrangements were made for a clinical advisor to call back: Three and a half hours later at 21:55hrs. That call was correctly processed and that call concluded with the day Harry day May Mrs The the clinician indicating that an ambulance was going to be arranged: At 22:21hrs on the 20d June 2016 nurse from the Urgent Care Desk then telephoned Mr Gill indicating that the ambulance was not now be being dispatched and that arrangements were going to be made to try and contact and out of hours doctor Mr Gill collapsed and died shortly thereafter. The conclusion reached by who is the 111 Clinical Quality and Nurse Lead for the