Robert Chandler
21 Feb 2019 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. inflatable chair failure causing improper lift and lack of safety straps
“The Mangar Elk inflatable chair was intended to be used to lift Mr [name redacted] to the ambulance. One section did not inflate and so Mr [name redacted] was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr [name redacted] before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used.”
2. equipment not checked daily and assistance not requested
“Staff are required to ask for assistance when required and are responsible for checking equipment daily. The evidence is that this is not always done.”
3. inadequate incident recording due to insufficiently charged tablet and incomplete paper records
“An electronic tablet was used initially to record the incident but this was not sufficiently charged to record all information. Paper records were not adequately completed.”
4. delayed implementation of investigation recommendations and clinical debrief
“The incident occurred in September 2018 and the internal investigation report with recommendations was completed in January 2019. Recommendations within the Report and in particular a clinical debrief had not taken place at the time of inquest (February 2019)”
Responses
2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust.pdf ↗· East of England Ambulance Service
Stated action
“The Trust has a process in place for vehicle/equipment daily checks to take place before the start of every shift. The vehicle daily checklist is completed by the crew and identifies any issues with the equipment on the vehicle. There are some exceptions to this if the crew are required to attend to the call immediately, however the general practice is to complete a vehicle daily check prior to the start of shift.”