Sally Perrons
9 Apr 2014 · Coroner Heidi Connor · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate paramedic intubation training
“The level of training associated with paramedic intubation - both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate”
2. absence of mandatory waveform end-tidal carbon dioxide monitoring
“Whether use of waveform end-tidal carbon dioxide monitors is now mandatory”
3. limited availability and insufficient training on waveform end-tidal carbon dioxide monitors
“Availability of these devices to staff, and training on how to use and interpret them”
4. potential prohibition of paramedic intubation without training reforms
“In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all”
5. inadequate dissemination of guidelines to frontline staff
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.”
Later report
“We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change.”
Responses
2014-0158-Response-by-Association-Ambulance-Chief-Executives.pdf ↗· Association of Ambulance Chief Executives
Stated action · July 2015
“Development of a national recognised teaching standard for the stepwise airway management and ventilation. This will include airway positioning, simple adjuncts and advanced techniques which include supraglottic devices and paramedic intubation. This standard will describe how a paramedic will be initially trained and deemed competent to practice the skill of intubation. This action to be completed by July 2015.”