Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed symptom recognition leading to missed emergency response
The earlier warning
Olive Nutt · 12 Jun 2018 · Russell Caller, London Inner (West)
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
What was promised
Stated action 1 · response to Olive Nutt (12 Jun 2018) · stated timescale: none stated
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”
judiciary.uk/…/2018-0233-Response-by-London-Ambulance-Service-N…
Stated action 2 · response to Olive Nutt (12 Jun 2018) · stated timescale: none stated
“During the afternoon of 29" January 2018 demand in the service was above that predicted and staffing levels both operationally and in the Clinical Hub were below the below the planned”
judiciary.uk/…/2018-0233-Response-by-London-Ambulance-Service-N…
Stated action 3 · response to Olive Nutt (12 Jun 2018) · stated timescale: September 2018
“The LAS recruitment drive is ongoing for operational staff and a specific recruitment programme for the Clinical Hub is taking place in September 2018 with a view to increasing the pool of staff trained in the Manchester Triage System and with specific Clinical Hub training.”
judiciary.uk/…/2018-0233-Response-by-London-Ambulance-Service-N…
What recurred
- 27 Apr 2022 · Raphael Gill · Jonathan Landau · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Olive Nutt · 12 Jun 2018
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
Later · Raphael Gill · 27 Apr 2022
“It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency”
What happened next
No web check of the stated actions has been published for this chain.