Learning from coroners’ reports could prevent deaths

PRESS RELEASE

  • 11th August 2020

Yesterday, Health Service Journal (HSJ) reported that the London Ambulance Service (LAS) NHS Trust is now looking into alternative defibrillators after receiving two warnings from Coroners Prevention of Future Deaths (PFD) reports, due to problems with their existing machines.[1] PFD reports are issued when, in the coroner’s opinion, the case they are reviewing requires action to be taken in order to prevent future deaths.[2]

Delays in defibrillation

The reports in question relate to the deaths of Najeeb Katende in 2016 and Mitica Marin in 2019.[3] In both cases, an issue had occurred when using the LP15 defibrillator, which had been started in ‘manual’ rather than ‘automatic’ mode. This resulted in the paramedic not initially realising the patient had a shockable heart rhythm and led to a delay before the first shock was administered. If the defibrillator had initially been in ‘automatic’ mode it would have detected a rhythm and prompted the paramedic to shock the patient.

In the coroner’s report into the death of Mitica Marin, it was noted that LAS had carried out a review of cases of delayed defibrillation with the LP15 and recognised the issue that this specific machine “defaults to manual mode requiring the user to switch to automatic mode before use”.[4] Garrett Emmerson, LAS Chief Executive, noted that they were now taking a series of actions to address this, “including putting warning stickers on the defibrillators and staff refresher training on how to use the machines”.[5]

Preventing future deaths

While this case focuses a specific safety in use issue concerning the LP15 defibrillator, it also serves to highlight the broader issue we have previously raised at Patient Safety Learning; failure to harness learning from PFD reports. We believe that by learning from PFD reports, patient safety can be improved and the reports can achieve their aim of preventing future deaths.[6]

One of our concerns in this regard is that learnings from PFD reports may be applicable beyond the organisation, however at present there appears to be no clear system of sharing learning more widely. We are pleased that LAS has identified this safety issue, however it is vital that this information is now widely shared so others can also take action to manage the risks to patients. If the concerns identified in PFD reports remain in silos, there is a danger that this could reoccur in a different trust.

At Patient Safety Learning, we believe there are a number of actions which could be taken to help address the current gaps in the system. Please refer to our previous blog on Learning from PFD reports to see these actions in detail.

[1] HSJ, Patient deaths prompt ambulance chiefs to look for alternative defibrillators, 10 August 2020. https://www.hsj.co.uk/patient-safety/patient-deaths-prompt-ambulance-chiefs-to-look-for-alternative-defibrillators/7028204.article

[2] The Coroners (Investigations) Regulations 2013, SI 2013/1629. https://www.legislation.gov.uk/uksi/2013/1629/part/7/made

[3] Edwin Buckett, Prevention of Future Deaths Report – Najeeb Katende, 21 April 2017. https://www.judiciary.uk/publications/najeeb-katende/; Graeme Irvin, Prevention of Future Deaths Report – Mitica Marin, 12 March 2020. https://www.judiciary.uk/publications/mitica-marin/

[4] Graeme Irvin, Prevention of Future Deaths Report – Mitica Marin, 12 March 2020. https://www.judiciary.uk/publications/mitica-marin/

[5] HSJ, Patient deaths prompt ambulance chiefs to look for alternative defibrillators, 10 August 2020. https://www.hsj.co.uk/patient-safety/patient-deaths-prompt-ambulance-chiefs-to-look-for-alternative-defibrillators/7028204.article

[6] Patient Safety Learning, Learning from Prevention of Future Deaths reports, 25 February 2020. https://www.patientsafetylearning.org/blog/learning-from-prevention-of-future-deaths-reports

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