UK Inquiry Tracker

Paul Murray

PFD Report All Responded Ref: 2015-0193

Date of Report 13 May 2015

Coroner Andrew Walker

Coroner Area London (North)

Response Deadline est. 8 July 2015

Community health care and emergency services related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 8 Jul 2015

Coroner's Concerns (AI summary)

Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.

View full coroner's concerns

_ _ That there were insufficient resources available for the London Ambulance service to meet the demand on the &th February 2013 at 12.19

Responses

Department of Health Central Government

5 Jun 2015

Action Taken
The London Ambulance Service carried out a serious incident investigation, resulting in plans to increase capacity through its modernisation programme, implementation of 'Intelligent Conveyance', consideration of a process for clinical review of repeated calls, and reminders to call takers to free text relevant information. (AI summary)

View full response

From the Lord Prior of Brampton Parliamentary Under Secretary of State for NHS Productivity (Lords) Department of Health Andrew Walker Richmond House 79 Whitehall HM Senior Coroner for Northern District of Greater London London North London Coroners Court SWIA 2NS 29 Wood Street Tel: 020 7210 4850 Barnet ENS 4BE 2 5 Jun 2015 Thank you for your letter to the Secretary of State for Health about the death of Paul Alexander Murray. I am responding as the Minister with responsibility for NHS performance policy at the Department of Health: was very sorry to hear of Mr Murray' s death and would be grateful if you would pass my condolences to his family. Your report gave details of Mr Murray'$ experiences following a call to London Ambulance Service on 8 February 2013. You were particularly concerned that there were insufficient ambulance resources available for the Service to meet the demand in the area at the time of the incident. As you may be aware, it is the responsibility of individual ambulance trusts to ensure that resources are aligned to demand. The Department of Health continues to work closely with its partners in the healthcare system including NHS England; Monitor and the Trust Development Authority (TDA) to monitor and support ambulance service performance. Furthermore; in recognition that the NHS is busier than ever; we are backing the NHS' future plan with an extra E8billion by 2020. As a result of this incident; I understand the London Ambulance Service carried out a serious incident investigation, with four consequent actions: 1_ The Trust plans to increase capacity through its modernisation programme and planning for winter; when demand increases_ 2 As part of the Trust's winter plans, Intelligent Conveyance" is aimed at reducing surges of demand at acute trusts.

3_ The Trust is considering a process of clinical review where multiple repeated calls report deterioration in a patient'$ condition, but the category of the call itself does not otherwise change. 4 Call takers have been reminded to free text any potentially relevant information on calls that may be important for clinicians undertaking a clinical review or enhanced clinical assessment_ Ihave also sent your report to NHS England to ensure wider awareness of the issues you have raised. Thank you for bringing this matter to our attention. L DAVID PRIOR

Sent To

Department of Health and Social Care

Response Status

Linked responses 1 of 1

56-Day Deadline 8 Jul 2015

All responses received

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 the 14lh February 2013 opened an inquest the death of Paul Alexander Murray 47 years old. The inquest concluded on Rtouehzzg-the February 2015. The conclusion of the inquest was Narrative" , the medical case of death was Ia Fatal cardiac dysrhythmia 1b Myocarditis_

Circumstances of the Death

Paul Alexander Murray died from the results of a myocarditis on the &th February 2015 that was likely to have or SO before. Mr Murray began to show symptoms and the first call was made to the London Ambulance Service at 12.00 There are three matters that are likely to have a bearing on Mr Murray'$ death Firstly that Mr Murray was developing the symptoms of a myocarditis such that he was vomiting and in some pain at the time of the first call to the London Ambulance Service. The Ambulance Service would not been able to associate the general symptoms with a myocarditis_ Secondly there were insufficient ambulances in circulation to respond following the second call at 12.19 if there had been sufficient ambulances and an ambulance had attended to Mr Murray it is likely that he would not have had the cardiac arrest as it is likely that had treatment been provided by the ambulance staff that treatment would have delayed the onset of Mr Murrays cardiac arrest Fax and begun day have

Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) Thirdly that had Mr Murray been taken to hospital following the call at 12.19 arriving there before his cardiac arrest it is likely that he would not have died when he did. Mr Murray did receive an emergency response by a first responder after a 4" call saying that Mr Murray had become unresponsive, a criteria that generates an emergency response_ Mr Murray was taken to hospital arriving at 14.50 pm where despite treatment he died.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.