Mrs Withers
PFD Report
Historic (No Identified Response)
Ref: 2015-0371
Coroner's Concerns (AI summary)
Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.
View full coroner's concerns
^ During the course ofthe Inquest the evidence revealed matters giving rise to concern. In my opinion thereIsa risk thatfuture deaths could occurunless action Istaken. In the circumstances It Is my statutory duty toreport toyou. 1) The policy In relation to obtaining a patient's medical history during the first 999 call, reporting an Incident.
2) The policy In relation to calling back a life llne/third party where the patient Is unable to receive calls.
3) The policy/procedure In relation to saving essential patient medical history In the ambulance service electronic data systems.
4) The policy In relation to staffabstraction toleranceand levels.
5) The policy and protocol In relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover ofpatient to hospital.)
2) The policy In relation to calling back a life llne/third party where the patient Is unable to receive calls.
3) The policy/procedure In relation to saving essential patient medical history In the ambulance service electronic data systems.
4) The policy In relation to staffabstraction toleranceand levels.
5) The policy and protocol In relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover ofpatient to hospital.)
Sent To
- East Midlands Ambulance Service
- Kettering General Hospital NHS Trust ›Kettering General Hospital
Response Status
Linked responses
0 of 3
56-Day Deadline
7 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
The investigation commenced on the19*^ February 2015. Apost mortem was conducted by , Consultant Histopathologist. Further evidence wasobtained in relation to the deceased's background and medical treatment by paramedics and hospital staff. East Midlands Ambulance Service provided a "Description and Consequences repoif. The resumed inquesttook place on the 18*^ June 2015. TheGP's evidence was read under rule 23. Live evidence wastakenfrom:
1. , Orthopaedic registrar at Kettering General Hospital
2. , Assistant Director ofthe Operations Centre for EMAS
3. (deceased'sson)
4. Consultant Histopathologist The finding atinquest was that on 30"^ January 2015 at22.10 hours, the deceased had a fall ather home. An ambulance conveyed her to Kettering General Hospital where death was confirmed at02.26 hours on 31®* January 2015. Anarrative conclusion was delivered in the following term "Mrs Withers' death was accidental howeverherdeath was contributed to by neglect The 2hour 50 minute delay between the 999 call being placed and the paramedic arriving probably did on the balance ofprobabilities contribute to Mrs Withers' death"
1. , Orthopaedic registrar at Kettering General Hospital
2. , Assistant Director ofthe Operations Centre for EMAS
3. (deceased'sson)
4. Consultant Histopathologist The finding atinquest was that on 30"^ January 2015 at22.10 hours, the deceased had a fall ather home. An ambulance conveyed her to Kettering General Hospital where death was confirmed at02.26 hours on 31®* January 2015. Anarrative conclusion was delivered in the following term "Mrs Withers' death was accidental howeverherdeath was contributed to by neglect The 2hour 50 minute delay between the 999 call being placed and the paramedic arriving probably did on the balance ofprobabilities contribute to Mrs Withers' death"
Circumstances of the Death
Mrs Withers was 77 years ofage. She suffered significant medical problems and r^uired constant home oxygen. Mrs Withers was attended athome by carers and the Rocket team. Mrs Withers suffered a fall sustaining injury and was immobile and unable to make telephone calls. Alifeline was activated. The paramedics arrived after a delay of2hours and 50 minutes. The Pathologist's findings were that the deceased suffered afracture of the left pubic ramus as a result ofa mechanical fall. This led toa significant blood loss into the soft tissues and the consequence of this significant haemorrhage resulted in cardiac arrest.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and Ibelieve you AND/OR your organisation, have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.