Raphael Gill
27 Apr 2022 · Coroner Jonathan Landau · South London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. patient not rescued due to delayed treatment
“The evidence of the medical expert was that Mr [name redacted] was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr [name redacted] was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine”
2. arrest influencing urgency assessment
“the arrest unduly influenced the assessment of urgency”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
This report
“It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency”
Responses
2022-0131-Response-from-London-Ambulance-Service.pdf ↗· London Ambulance Service NHS Trust
Stated action · early Autumn 2022
“we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.”