Caragh Melling
PFD Report
Historic (No Identified Response)
Ref: 2016-0167
Coroner's Concerns (AI summary)
The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.
View full coroner's concerns
The MATTERS OF CONCERN are as follows. –
(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing.
The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool. They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1).
I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken.
(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing.
The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool. They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1).
I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken.
Sent To
- NHS Pathways
Response Status
Linked responses
0 of 1
56-Day Deadline
22 Jun 2016
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
Caragh Melling died on 27 December 2014, aged 37 years, from an unascertained cause.
An inquest into her death was heard on 27 April 2016, at which I recorded a conclusion of natural causes. I was satisfied that, although the medical cause of death could not be determined on the balance of probabilities, her death was not unnatural.
An inquest into her death was heard on 27 April 2016, at which I recorded a conclusion of natural causes. I was satisfied that, although the medical cause of death could not be determined on the balance of probabilities, her death was not unnatural.
Circumstances of the Death
Ms Melling collapsed at home on 27 December 2014, after an episode of dizzyness.
Emergency services were called by Ms Melling’s partner, however the triaging failed to recognise that she was suffering from agonal breathing. As a consequence no advice was given to her partner to commence resuscitation. On arrival of the ambulance crew Ms
Melling was found to be in cardiac arrest.
Resuscitation attempts were unsuccessful and Ms Melling died shortly after arrival at hospital.
Emergency services were called by Ms Melling’s partner, however the triaging failed to recognise that she was suffering from agonal breathing. As a consequence no advice was given to her partner to commence resuscitation. On arrival of the ambulance crew Ms
Melling was found to be in cardiac arrest.
Resuscitation attempts were unsuccessful and Ms Melling died shortly after arrival at hospital.
Copies Sent To
Midlands Ambulance Service NHS Trust
I am also under a duty to send the Chief Coroner a copy of your response
Assistant Coroner R Brittain
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.