UK Inquiry Tracker

Monica Lewis-Hinds

PFD Report Historic (No Identified Response) Ref: 2016-0133

Date of Report 6 April 2016

Coroner Selena Lynch

Coroner Area London (South)

Response Deadline ✓ from report 6 June 2016

Community health care and emergency services related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.

View full coroner's concerns

_ _ The protocol used by the London Ambulance Service to triage calls includes a question about the_type of fit,but the question is not posed by the call handler to the caller, and the section is only completed if the caller offers the information. In view of the potential consequences for the patient, this part of the protocol may require amendment, so that the question is pre-emptively in all cases_

Sent To

London Ambulance Service

Response Status

Linked responses 0 of 1

56-Day Deadline 6 Jun 2016

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

Circumstances of the Death

Ms Lewis-Hinds suffered from poorly controlled epilepsy. An ambulance was requested to attend her home just after midnight on 16th January 2015 as she had suffered seizure The seizure was atypical, something which raises the priority of the call to Red 2 ( response time of 8 minutes). The type of seizure was not ascertained by the call handler, resulting in a delayed response. It was not possible to ascertain whether the delay caused or contributed to the fatal outcome

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_