Independent investigation: Fr Paul Bennett, Aberdare (2007)

In relation to the repeated requests for Mrs Bennett to check on her husband, given that the assailant was still present at the scene when Father Paul’s wife made the 999 call, we believe that control room operator should apply … Read more In relation to the repeated requests for Mrs Bennett to check on her husband, given that the assailant was still present at the scene when Father Paul’s wife made the 999 call, we believe that control room operator should apply the same standards of scene safety to callers as for ambulance personnel. The telephone scripts used by WAST should be reviewed and protocols put in place to ensure the safety of the caller and other members of the public at the scene, with particular attention given to the section asking the caller to check on Father Paul. Show less

In relation to the initial delay in identifying the correct address during the 999 call, we believe that the value of installing appropriate software to assist with address identification in all WAST control should be examined to ensure delays with … Read more In relation to the initial delay in identifying the correct address during the 999 call, we believe that the value of installing appropriate software to assist with address identification in all WAST control should be examined to ensure delays with the identification of the location of incidents are minimised. Show less

Prior to the arrival of the ambulance crew, first aid was not given to Father Paul. Bystander resuscitation should be encouraged for all calls where patients are unconscious and not breathing, unless the patient is unequivocally deceased as defined by … Read more Prior to the arrival of the ambulance crew, first aid was not given to Father Paul. Bystander resuscitation should be encouraged for all calls where patients are unconscious and not breathing, unless the patient is unequivocally deceased as defined by the WAST ROLE/DNAR policy. Show less

The WAST Lone Worker policy needs to be reviewed to ensure that patient care is not compromised by withholding solo resources. The use of meeting points and methods of liaising with the police in order to ensure the safety of … Read more The WAST Lone Worker policy needs to be reviewed to ensure that patient care is not compromised by withholding solo resources. The use of meeting points and methods of liaising with the police in order to ensure the safety of the crew should be addressed. Show less

WAST should work with the police to clarify the boundaries of police roles and responsibilities in relation to deciding that a patient is deceased and advising that resuscitation is not necessary.

WAST should work with the police to produce a clear set of guidelines for the police, similar to their own DNAR guidance for conditions unequivocally associated with death.

WAST staff, including control staff and ambulance crew should receive regular training in clinical, and operational policies which may be used infrequently, but in the most serious circumstances.

This policy should be reviewed taking into account that a non-shockable rhythm could include an agonal rhythm or pulseless electrical activity where resuscitation would be appropriate. Consideration should be given to removing point i) from the list to avoid confusion … Read more This policy should be reviewed taking into account that a non-shockable rhythm could include an agonal rhythm or pulseless electrical activity where resuscitation would be appropriate. Consideration should be given to removing point i) from the list to avoid confusion as asystole, as covered in point v) is the only rhythm where DNAR should be considered. The policy itself is unclear as there appear to be contradictions in relation to ROLE/DNAR criteria and guidelines, with particular attention needed to be given to the definition of terminology. Show less

The Health Board should engage with health and social care providers to facilitate arrangements for a co-ordinated multi-agency response to serious incidents such as this homicide, to provide an appropriate and timely response to the needs of individuals and communities … Read more The Health Board should engage with health and social care providers to facilitate arrangements for a co-ordinated multi-agency response to serious incidents such as this homicide, to provide an appropriate and timely response to the needs of individuals and communities affected. That should include: (cid:120) Identifying appropriate sources of help and support. (cid:120) Establishing a system for engaging services, recognising the need to be pro-active in offering services. (cid:120) Ensuring that front line providers (e.g. GPs, A&E staff, social workers, community leaders) are aware of the arrangements, and how to mobilise them. (cid:120) Ensuring links with police family liaison officers, victim support scheme and others so they can provide access to the arrangements for those who need them. Show less

Patient records should be reviewed thoroughly at every attendance at A&E, in particular to highlight any developing concerns that may emerge in light of past attendances.

Communication between the A&E department, other departments and GPs is subject to formal arrangements, including immediate telephone contact when necessary, formal written reports and routine auditing.

Measures should be taken to ensure the correct logging of calls and that urgency is assessed effectively, followed up by an appropriate response.

The new arrangements in place, relating to out of hours access to mental health services, are subject to formal auditing arrangements by the Health Board.

Communication with other agencies is timely and effective and that any follow up is carried out fully and comprehensively.

All agencies need to meet together in order to discuss how to handle complicated cases and develop a comprehensive care pathway.

Records are accurately documented and reviewed in order to aid with spotting any patterns which may emerge in relation to the risk assessment process.

Record management arrangements are robust and routinely audited and that records are kept secure at all times.

Joint working across agencies is effective and that responses are well coordinated.

Organisations issue a proportionate response in accordance to the assessed level of risk.

Organisations ensure that risk management processes are robust and that a long term view is taken in relation to risk management.