Shanté Turay-Thomas
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of specialist allergy care
“At the time of her death, [name redacted] was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.”
2. Emerade AAI sold singly
“The Emerade AAI is sold singly. It could be sold in boxes of two as the norm and only singly in the alternative.”
3. dose not increased after AAI switch
“When [name redacted]'s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs.”
4. CCG failed to advise dose increase after AAI switch
“The CCG failed to draw prescribers' attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included [name redacted]).”
5. CCG gave incorrect training guidance
“The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice.”
6. inadequate audit of 111 call errors
“During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways.”
Linked reports
Earlier report
“That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities”
This report
“When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways.”
Earlier report
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg.”
This report
“When [name redacted]'s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs.”
Responses
2020-0124-Association-of-Ambulance-Chief-Executives_Redacted.pdf ↗· Association of Ambulance Chief Executives
Stated action
“we have worked closely with NHS England and other partners to reduce the variation as far as possible. Specifically, in relation to anaphylactic shock we have previously made representation to NHS England through the now disbanded Ambulance Response Programme Delivery Group (ARP DG) Chairman: Professor [name redacted] C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: [name redacted] and the Emergency Call Prioritisation Advisory Group (ECPAG) requesting that the clinical coding inconsistency”
2020-0124-Response-from-Advanced_Redacted.pdf ↗· Advanced Health & Care Ltd
2020-0124-Response-from-Bausch-Lomb_Redacted.pdf ↗· Bausch & Lomb UK Ltd
2020-0124-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf ↗· Department of Health and Social Care
2020-0124-Response-from-Enfield-CCG.pdf ↗· Enfield Clinical Commissioning Group
2020-0124-Response-from-London-Ambulance-Service_Redacted.pdf ↗· London Ambulance Service NHS Trust
2020-0124-Response-from-NHS-Digital_Redacted-1.pdf ↗· NHS Digital
Stated action · 20th December 2019
“NHS Digital has developed an extensive audit framework that applies to providers using NHS Pathways. This was described in NHS Digital's: supplementary second witness statement dated 20th December 2019; submissions on conclusion dated 3 January 2020; and PFD submissions dated 17 January 2020.”
Stated action
“NHS Digital also offers regular 'audit levelling' sessions to providers in order to achieve good and consistent practice.”
Stated action
“The detailed requirements for auditing call handlers (including clinicians) establish audit frequencies, and standards against which audits should occur. These include criteria for auditing and requirements by way of qualification and training of those carrying out any audit.”
Stated action
“Ensuring the proper operation of the audit system and management of failed call audits is the responsibility of the provider, within the framework provided by NHS Digital.”
Stated action
“NHS Digital has since changed its categorisation.”
Stated action · October 2019
“Following the Ambulance Response Program, NHS England led (supported by NASMED and ECPAG) a "clinical coding review" in May 2019, reviewing the category 1 ambulance response definition. Consequently, it was decided that symptoms which may suggest life-threatening anaphylaxis should receive a category 1 ambulance response and the necessary changes were made by NHS Pathways. These were beta tested in September 2019 and deployed nationally from October 2019”
2020-0124-Response-from-NHS-England_Redacted.pdf ↗· NHS England
2020-0124-Response-from-NICE_Redacted.pdf ↗· London Ambulance Service NHS Trust
Stated action
“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”
2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf ↗· Advanced Health & Care Ltd
Stated action · October 2019
“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”