DAVID LESLIE SELMAN · Prevention of Future Deaths report

On 13 February 2013 an Inquest was opened into the death of DAVID LESLIE SELMAN, then aged 38. The Inquest concluded at a hearing on 25 September 2013. The conclusion of the inquest was a narrative verdict, a copy of which I attach, the medical cause of death being multiple drug toxicity.

4.1 Mr Selman had a history of mental illness and suffered from schizophrenia and epilepsy for which he took prescription drugs. He also had a history of taking “legal highs”. Just prior to his death on 11 February 2013 Mr Selman had consumed a large amount of legal highs which had an adverse reaction with the prescription drugs that he was then taking.

4.2 In the early evening of 11 February 2013 he had a drink at All Bar One, a public house on High Street, Oxford, when the staff at All Bar One noted unusual behaviour on the part of Mr Selman, including shaking and spasms. The bar staff were sufficiently concerned that they called for an ambulance at 17:51 hours.

4.3 As I understand is usual practice, because Mr Selman was in a public house, and the ambulance service were not given assurances that it was safe to attend, the police were called and attended at All Bar One at 18:05.

4.4 At the same time the ambulance crew who were originally notified were told to stand back. Unfortunately, that message reached the crew but they thought the control room had told them to stand down and they therefore returned to the hospital. (The ambulance engaged was sub-contracted by South Central Ambulance Service to Surrey Ambulance Service.)

4.5 At 18:08 the police officers attending contacted their control room to say that they were on the scene to confirm that an ambulance was required. Effectively, that it was safe to approach. That was relayed to the control room for the ambulance service at 18:17 and the crew were then notified to attend the scene. As they had deployed back to the hospital it took them a further ten to twelve minutes to attend to Mr Selman at 18:33 hours. The total time from the original call until the ambulance arrived was, by my calculation, 42 minutes.

4.6 Because of the delay in the ambulance arriving a further call was made and further information given to the control room as regards Mr Selman’s state. That information was not passed on. Had it done so I understand there could have been a reassessment of whether a paramedic should have been deployed as opposed to the ambulance technician who attended. A paramedic may have been in a position to provide an advanced level of care.

5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back.

5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem.

5.3 It is clearly important that a continual assessment of the patient’s presenting symptoms are related to the ambulance crew and how best to deploy resources given the circumstances of any individual case. The evidence at the Inquest was that no such assessment was undertaken.

I should make it clear that I found no evidence that an earlier attendance by the ambulance crew would have resulted in a different outcome for Mr Selman who sadly went into cardiac arrest just prior to arriving at the John Radcliffe Hospital and, despite the best efforts of the staff at the hospital, he could not be revived.

I would also say that ████████, on behalf of your service, provided me with a helpful report which assisted my enquiry and gave a very open and honest account of his assessment of the circumstances of this case.