George Boulton
6 Jul 2015 · Coroner Lydia Brown · Leicester City and Leicestershire South
The coroner's concerns
1. stroke symptom response delay
“response to potential stroke symptoms should be on an emergency basis, in accordance with”
2. lack of emergency call routing system
“bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission”
3. stroke patient escalation failure
“East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time”
4. delayed intervention risk
“This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse”
Responses
2015-0255-Responses.pdf ↗· East Midlands Ambulance Service
Stated action · 28 August 2015
“immediate action we will communicate with our lead commissioners to disseminate the following message to all GP's and Bed Bureau. If a patient's condition presents an immediate threat to life or relates to new symptoms of Stroke or Cardiac chest pain call 999 for an emergency response”