Sarah Ferneyhough
29 Sept 2020 · Coroner Caroline Beasley-Murray · Essex
The coroner's concerns
1. automatically categorised as category 3
“The deceased's call was described as an "abandoned call" and thereafter automatically categorised as a category 3 A review of this practice is required.”
2. all reported medical conditions categorised no higher than category 3
“A review is required as to whether it is appropriate for all reported medical conditions to be categorised no higher than category 3”
3. duty EOC not listening to recording or receiving full medical details
“In the situation leading up to Ms [name redacted] death, the duty EOC who had authority to upgrade the categorisation of the call did not listen to the recording of the "abandoned" call and was not provided with full details of any medical information given. Measures could be put in place to ensure that the duty EOC or other person who has authority to upgrade the categorisation of calls is asked to listen to the recording of the "abandoned" call or provided with full details of any medical information”
Responses
2020-0187-Response-from-East-of-England-Ambulance-Service-REDACTED.pdf ↗· AACE's National Directors of Operations Group
Stated action · December 2020
“The Trust has already introduced a new EOC Standard Operating Procedure (ESOP) specifically for Mental Health calls and has now made a further revision to the document. Within this ESOP, guidance is given that if the call is abandoned and therefore has incomplete triage (i.e. we haven't been able to seek responses to all the triage questions), and the information provided suggests the patient is actively at risk due to action they have already taken, or currently taking to harm themselves or end”