Sabrina Stevenson
30 Mar 2015 · Coroner R Brittain · London North (Inner)
The coroner's concerns
1. increasing response times
“Ambulance response times were the focus of evidence provided at the inquest”
2. staffing shortages
“A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall”
3. missed pregnancy diagnosis
“I heard from the consultant [name redacted] that all women of childbearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing”
4. inadequate extraction knowledge
“Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove [the deceased] to the ambulance”
5. insufficient training documentation
“Evidence has been provided that specific training 'case studies' will be or have been published on the issues of ectopic pregnancy and transient capacity”
6. lack of system improvements
“The potential for systems improvements, such as automated recategorisation, clinical retriaging and feedback to callhandlers regarding current timeframes were raised during the inquest”
Responses
2015-0126-Response-by-College-of-Paramedics.pdf ↗· College of Paramedics
2015-0126-Response-by-London-Ambulance-Service.pdf ↗· London Ambulance Service NHS Trust
Stated action · 23 April 2015
“On 23 April 2015 I wrote to all LAS staff to inform them of the additional investment the LAS had secured.”
2015-0126-Response-by-NHS-England1.pdf ↗· NHS England
Stated action · September 2015
“The agreed improvement programme also includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.”
Stevenson-2015-0126b.pdf ↗· London Ambulance Service NHS Trust
Stated action · 25 May 2015
“am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has 2 been addressed.”
Stevenson-2015-0126c.pdf ↗· London Ambulance Service NHS Trust
Stated action
“I am concerned by evidence provided from LAS that there are 400 vacant 2 positions within the Trust. This connotes a significant recruitment issue for the profession, which could risk future deaths occurring simply through a lack of available trained paramedics”