Maureen Wharton
6 Dec 2019 · Coroner Terence Carney · Gateshead & South Tyneside
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of inquiry into location and support
“No enquiry was made of [the deceased] as to the nature of her location and the potential support or assistance readily at hand or otherwise.”
2. failure to identify familial or social support
“No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger”
3. absence of protocol for non-ambulance response
“No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation”
4. absence of inter-agency arrangements
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger”
5. delayed ambulance arrival
“a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at [the deceased]'s side”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers can unintentionally build a picture about an individual.”
This report
“c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation”
Closely relatedConfidence 0.80 · moderate
This report
“No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger”
Later report
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories”
Closely relatedConfidence 0.85 · high
This report
“Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at [the deceased]'s side.”
Later report
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Closely relatedConfidence 0.85 · high
This report
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.”
Later report
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Responses
No published response was found on judiciary.uk.