Paul Dow
10 Apr 2024 · Coroner Matthew Cox · Manchester North
The coroner's concerns
1. overdose of medication leading to self-harm
“Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3”
2. lack of clinical involvement during emergency calls
“There was no involvement from a clinician at the time of either call”
3. patient alone in hotel room with possible loss of consciousness not escalated
“Mr [name redacted] was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms [name redacted], the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr [name redacted] had lost consciousness but the call made at 18.35 was not escalated”
Responses
2024-0192-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2024-0192-Response-from-North-West-Ambulance-Service.pdf ↗· North West Ambulance Service NHS Trust
Stated action
“Based on this review the Clinical Navigator will make a decision as to whether the call (1) needs to be upgraded immediately, (2) should remain as a category 3 response and await ambulance dispatch accordingly or (3) requires further triaging. This is now the first line of clinician review in these types of calls and ordinarily takes place within 15 minutes of the 999 call being concluded.”