Coroner issues Regulation 28 Prevention of Future Deaths Report following a “failure of the Medical Priority Despatch System”

His Majesty’s Coroner Brendan Allen, Area Coroner for Dorset, has issued a “Regulation 28 Report to prevent future deaths to the International Academics of Emergency Dispatch, following a 3 day inquest into the tragic death of Mr Kenneth Adams on 19 October 2021.

Mr Adams’ family were represented throughout the coronial process by Partner, Gary Smith of Prince Evans Solicitors LLP [Insert as hyperlink:] and barrister Edward Ramsay of 12 Kings Bench Walk.

Factual Findings

The Coroner found that Mr Adams contacted the ambulance service at 04.06am on 19 October 2021 having fallen in his home 45 minutes earlier. He informed the Emergency Medical Dispatcher that he had sustained an injury to his scalp, lost a significant amount of blood and was having difficulty stopping the bleeding.  

The Ambulance service triaged Mr Adams on the basis of a framework known as the “Medical Priority Dispatch System”, a tool which is used nationally.  Mr Adams was put into a disposition of “17-b-01”, meaning “fall, possible dangerous area”.  This translated into a category 3 emergency response.  The national target set by the Department of Health is to attend category 3 incidents within 120 minutes on at least 90% of occasions, with an average response time of 60 minutes.

The Medical Priority Dispatch System, however, did not elicit that Mr Adams was taking blood thinning medication which is routinely prescribed throughout the UK.

Two further calls were made to the Ambulance Service at 07.53 and 10.25am.  On each occasion, the Coroner found that “Mr Adams explained worsening symptoms”.  In particular, he found during the 10.25 telephone call that Mr Adams speech was “slow and slurred” and that at this point he had “likely experienced a reduced blood pressure due to blood loss”.  However, although on each of these further occasions Mr Adams was re-triaged by the ambulance service using MPDS, on neither occasion did his deteriorating symptoms lead to a recategorisation and escalation of the priority of emergency response, which was already overdue.

The Coroner found that the Medical Priority Dispatch System was limited to questioning whether Mr Adams’ blood loss was “spurting or pouring”.  However, the Coroner found that this represented a “lacuna” within the system, as on the medical evidence “any laceration of the scalp would result in low pressure bleeding” i.e. it would never spurt or pour due to the head being a highly vascular area.

The first ambulance resource arrived at Mr Adams’ property at 11.56am by which time he had collapsed and was in cardiac arrest.  He tragically died later that day.

Coroner Allen found that Mr Adams “died as a consequence of an accident to which a failure to provide emergency medical assistance in a timely manner more than minimally contributed”. He further found there was “a failure of the Medical Priority Despatch System to acknowledge and assess persistent bleeding from a scalp injury against a background of anti-platelet medication”.  It is on these findings that His Majesty’s Coroner issued a Regulation 28 Report to the “International Academics of Emergency Dispatch”, which requires them to “investigate and respond to his findings”.

Understandably, given the tragic circumstances which are a matter of public interest, the matter has subsequently generated considerable national and local press coverage.

Prince Evans Solicitors LLP’s Partner, Gary Smith says “these tragic circumstances provide an example of the importance of thorough investigation and representation for bereaved families during coronial proceedings.  Unfortunately, organisations subject to enquiry often become defensive, making it difficult for families to establish the truth behind events and for lessons to be learned for the wider good (where appropriate).  This is where we can help”.

Prince Evans Solicitors LLP represent the interests of families during coronial proceedings.  Should you wish to obtain representation please contact us on 020 8567 3477 or