Anthony McCormack
4 Sept 2017 · Coroner Fiona Borrill · Manchester (City)
This report repeats 1 earlier warning, and was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of staff training in cardiac arrest recognition and first aid
“The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR”
2. procedures fail when Tempus system unavailable
“The adequacy and effectiveness of the procedures followed by Emirates staff in the event that the Tempus system is unable to provide assistance which was the case here”
3. ambulance response targets not met causing delays
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources in November 2015 (for provision of more ambulances and recruitment of an additional 400 staff) I was also informed since April 2017 none of the nationally set targets have been met by any ambulance trust in England and Wales namely, a Red 1 response within 8 minutes 75% of the time, Red 2 within 19 minutes 95% of the time, I was”
4. single paramedic insufficient for advanced care
“Consequent on the above and in this specific case there was only one paramedic on duty at any one time for the whole of Manchester Airport. Such paramedic being required to carry out Basic Life Support alone and unable to start Advanced Life Support”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
This report
“NWAS failed to meet target times which are nationally set by the Department of Health”
Closely relatedConfidence 0.90 · high
This report
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources”
Later report
“target response times are still routinely not being met nationally.”
Closely relatedConfidence 0.90 · high
This report
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health”
Later report
“under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”
Identical hazardConfidence 0.90 · high
This report
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health”
Later report
“The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Closely relatedConfidence 0.90 · high
This report
“The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR”
Later report
“That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest”
Responses
2017-0241-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels.”
2017-0241-Response-by-Emirates.pdf ↗· Emirates Airlines