Josephine Barker
7 Mar 2022 · Coroner Jessica Russell-Mitra · County of Surrey
The coroner's concerns
1. lack of full triage leading to category 3 response
“initial early exit of the first 999 call without full triage- this results in a category 3 response. There is no reason full triage could not have continued”
2. failure to trigger major trauma protocol
“London Ambulance have a different major trauma protocol to SECAMBS and the fact that [name redacted] had been potentially hit by a car - even moving slowly- and had a head injury would have been enough for the Major Trauma protocol for London Ambulance. SECAMBS major trauma protocol was not triggered because even if she had been hit by a car it was not moving fast enough to justify a major trauma category (cat 2)”
3. absence of Clinical Safety Navigator causing missed priority escalation
“There was no Clinical Safety Navigator in place to manage the Welfare Stack. This is an alert that gives an indication to those viewing the list of cases waiting for an ambulance of the priority of the call within its category. [name redacted]'s case had a number of features which would have led to it becoming a priority within its category and potentially being upgraded: the incident was outside and therefore less safe and comfortable than waiting in a home/workplace; the day was very cold and there was a risk”
4. absence of clinician input during prolonged call handling
“At no point did a clinician have any input into the calls after the initial question from the call handler of call 1 as to whether this was major trauma or not and therefore there was no clinical assessment by SECAMBS of [name redacted]'s condition over the following two and a half hours: she was vomiting for over two hours after the fall, she had fluctuating consciousness and was rousable to shaking and not to voice. She had had a tonic-clonic seizure and had potentially been injured by being hit by a car.”
5. missed clinical review at 2 hour mark
“There should have been a clinical review at 2 hours. I have heard that there was not because there were not enough clinicians available”
6. NHS Pathways limitation with fluctuating consciousness
“There is a concern over the NHS Pathways tool's ability to deal with fluctuating consciousness. This is because there is only an assessment on conscious or on unconscious so moving between the two states triggers the call handler to move into the conscious or unconscious pathway respectively but is not able to take into account fully that conscious level is impaired or mixed”