Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Hannah Royle · 4 Oct 2021 · Karen Henderson, West Sussex
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
judiciary.uk/…/hannah-royle-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Hannah Royle (4 Oct 2021) · stated timescale: October 2021
“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken: 1. Work has been undertaken on a focused area of learning known as a”
judiciary.uk/…/2021-0327-Response-from-South-East-Coast-Ambulan…
Stated action 2 · response to Hannah Royle (4 Oct 2021) · stated timescale: none stated
“Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability.”
judiciary.uk/…/2021-0327-Response-from-South-East-Coast-Ambulan…
Stated action 3 · response to Hannah Royle (4 Oct 2021) · stated timescale: none stated
“The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.”
judiciary.uk/…/2021-0327-Response-from-South-East-Coast-Ambulan…
3 further stated actions are listed on the full chain page.
What recurred
- 30 Sept 2024 · Megan Williams · James Dillon · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Hannah Royle · 4 Oct 2021
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
Later · Megan Williams · 30 Sept 2024
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented”
What happened next
No web check of the stated actions has been published for this chain.