Helen Sheath
27 Jan 2020 · Coroner Emma Whitting · Bedfordshire and Luton
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed emergency response
“from the information provided on this call, that [the deceased] had locked herself in the bathroom and was threatening to self-harm by ingesting a substance, the call handler selected the set of questions titled”
2. ambulance diversion
“Although a Double Staffed Ambulance (DSA) was dispatched at 18.30 hours, it was diverted on route to a higher priority emergency call”
3. missed early intervention
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier (potentially just before or just after [the deceased] had ingested the sodium nitrate) which could potentially have altered the outcome.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier”
Later report
“The evidence I heard at inquest was that the call was coded at 25-C-1, which was as a Category 3 call.”
Responses
2020-0107-Response-from-Association-of-Chief-Executives_Redacted.pdf ↗· Association of Ambulance Chief Executives