Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Winston Llewellyn Johns · 30 Oct 2013 · Louise Hunt, Powys Bridgend and Glamorgan Valleys
“The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.”
judiciary.uk/prevention-of-future-death-reports/johns-2013-0279
What was promised
No published response from Department of Health and Social Care was found for the earlier reports.
What recurred
- 21 May 2015 · Barbara Patterson · Carly Henley · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Winston Llewellyn Johns · 30 Oct 2013
“The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.”
Later · Barbara Patterson · 21 May 2015
“During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non Clinical call handlers to issue CPR advice unless a patient has stopped breathing.”
What happened next
No evidence found either way · a stated action in a response
“You're in the grocery store, at the gym, or standing in a hospital hallway when someone collapses. They appear unconscious - but then you notice something unsettling: they're making sounds. Labored, irregular, almost snoring-like gasps. Their chest seems to rise slightly. Your brain registers one thing: they're breathing. So you wait, you call for help, and precious seconds tick away.”
Agonal Breathing: Why It Delays CPR and How to Recognize It - ACLS · affordableacls.com/…/recognizing-agonal-breathing-misunderstood…
“Agonal breathing or agonal respirations are medical terms used to describe insufficient breathing that often sounds like snoring, snorting, gasping, or labored breathing. The person will appear to be choking or having an involuntary gasp reflex. Agonal breathing is not true breathing and often indicates that someone is suffering from a severe medical emergency like cardiac arrest.”
Agonal Breathing: Gasping, Respiration, Sound & What to Do · avive.life/blog/agonal-breathing-everything-you-need-to-know
No evidence found does not mean the action did not happen.