Najeeb Katende · Prevention of Future Deaths report

Following the death of Master Najeeb Katende, aged 15 years, on the 10th October, 2016 an investigation into his death was carried out which concluded at the end of the inquest on the 10th April, 2017. I made a narrative determination, which I attach.

At about 10am on the 10th October, 2016 Najeeb collapsed at school. A paramedic from LAS attended and was with Najeeb by about 10.12am.

The paramedic considered that Najeeb was in cardiac arrest and used at LP15 defibrillator on him in manual mode. He interpreted the readings from that device as showing that Najeeb had a non-shockable heart rhythm and did not defibrillate him.

At about 10.36am, a subsequent heart rhythm check was carried out by an Advanced Paramedic (who had by then attended the scene) which showed that Najeeb had, in fact, a shockable rhythm. He was then defibrillated 6 times but was pronounced dead at 11.46am at hospital.

The data from the LP 15 device was downloaded and analysed. It showed that Najeeb had a shockable rhythm when first tested at 10.12am.

Accordingly, Najeeb was not defibrillated for a period of about 24 minutes between 10.12am – 10.36am.

The medical cause of death was found to be Sudden Cardiac Death Syndrome.

I found that the delay in defibrillating Najeeb significantly reduced his chances of survival although I did not find, on the balance of probabilities that he would have survived had this been done earlier.

1. Evidence was given by ████████ (Consultant Paramedic) that:

• Based on LAS statistics the survival rate from cardiac arrest, where there is a shockable rhythm is around 31% when defibrillation occurs;
• This is to be contrasted against a survival rate of around 9% for all presenting rhythms;
• For every minute of cardiac arrest where a shockable rhythm is present and no defibrillation is carried out, survival decreases by approximately 7-10%.

2. Evidence was also given from other Ambulance staff that:

• Despite the presence of other staff between 10.12am and 10.36am, no cross check was made as to whether Najeeb had a shockable rhythm;
• If an Automated External Defibrillator, such as those used by members of the public had been applied, this would have detected a shockable rhythm and would have proceeded to defibrilate Najeeb.

3. I consider that it would be of great benefit if LAS were to take the following steps, namely training and instruction to staff:

• Actively cross check with another clinician whether a shockable rhythm is present when attending an incident of this sort;
• Use the defibrillator in AED mode when first attending as a matter of routine, or at the very least if uncertain when interpreting a heart rhythm;
• Further educate on the interpretation of shockable rhythms from readings provided by defibrillator devices.