Oliver Hall
17 Jun 2019 · Coroner Nigel Parsley · Suffolk
The coroner's concerns
1. failure in transfer of patient disposition information
“It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground”
2. delayed ambulance response in septicaemia
“in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient's condition would have rapidly deteriorated”
3. lack of clarity in sepsis treatment guidance
“it was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee”
Responses
2019-0198-response-by-Association-of-Ambulance-Chief-Executives.pdf ↗· Association of Ambulance
Stated action · 2020/21
“during 2020/21 elements of the new National Emergency Services Mobile Communication Programme will be implemented across all ambulance services and this will include a greater ability to manage information through the new National Mobilisation Platform”
2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust.pdf ↗· East of England Ambulance Service
Stated action
“The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system, some of which also use the same triage system (Pathways) as UK 111 providers.”
2019-0198-Response-by-NICE.pdf ↗· N.I.C.E