UK Inquiry Tracker

Steven Jackson

PFD Report Historic (No Identified Response) Ref: 2015-0422

Date of Report 2 November 2015

Coroner Caroline Beasley-Murray

Coroner Area Essex

Response Deadline est. 28 December 2015

Community health care and emergency services related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.

View full coroner's concerns

In the circumstances it is my statutory duty to report lo you: The paramedic who attended at around 10.0Oam gave evidence which indicated that she did not seem to have learned from the events in March 2014. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively: There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as t0 when it is appropriate to convey a patient to hospital.

Sent To

Bevan Brittan Law Firm
East of England Ambulance Service NHS Trust ›East of England Ambulance Service
General Medical Council
Irwin Mitchell Solicitors
Southend Hospital Legal Services
Weightmans Solicitors

Response Status

Linked responses 0 of 6

56-Day Deadline 28 Dec 2015

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 29th January 2015 | commenced an investigation into the death of Steven David Jackson. The investigation concluded at the end of the inquest on 27ih October 2015. conclusion of the inquest was a narrative verdict: The cause of death was Ia) Acute Epiglottitis 0 beta haemolytic streptococcus group C as causative organism. Narrative conclusion:- At 6.26am on the 5"6 March 2014, Steven Jackson attended Southend Hospital andwas assessed by an out of hours doctor: At around 1o:ooam ambulance personnel were called to his home and gave him advice. At roopm ambulance personnel again attended after he had collapsed He wvas conveyed to Southend Hospitalwhere he died at 14:26pm There were very serious_ failings in the care Mr Jackson receivedfrom the ambulance staff With appropriate, timely treatment, Mr Jackson would most lieely have survived

Circumstances of the Death

Please see box 3 above: The

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. Your RESPONSE You are under a to respond to this report within 56 days of the date of this report, namely by the 15lh January 2016. I, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Copies Sent To

Murray duty duty