Glyn Ackerley · Prevention of Future Deaths report

On 08 September 2022 I commenced an investigation into the death of Glyn ACKERLEY aged 56. The investigation concluded at the end of the inquest on 22 November 2022. The conclusion of the inquest was that Glyn Ackerley died after becoming unresponsive at home on 4 September 2022, the cause of which cannot be determined.

Glyn Ackerley had a number of health issues which necessitated him taking pain relieving medication including ████████.

On 4 September 2022 he reported to his wife that he had swallowed ████████ and left the address. His wife telephoned for an ambulance (North West Ambulance Service) at 21.48 and the call was triaged as a category 3 response based on the NHS Pathways algorithm. At 22.37 the police called the ambulance service and advised that he was having difficulty breathing. The call was upgraded to a category 1 response and the ambulance arrived at 22.52

The evidence was inconclusive as to whether Mr Ackerley had in fact swallowed ████████ as he reported to his wife, with levels of ████████ found in his blood post mortem being consistent with both an overdose and the therapeutic range.

(brief summary of matters of concern)
The current NHS Pathways process does not differentiate between a high risk and low risk overdose, categorising all such calls without additional symptoms as category 3. Evidence was heard during the inquest that time is of the essence when dealing with an opiate overdose, and giving reversal medication prior to any respiratory depression or cardiac arrest will likely have a better outcome. In light of the concerns raised by this case, NWAS have reviewed their process and added in additional questions for call handlers to identify high risk medications involved in an overdose, which they then automatically categorise as a category 2 and send for a call back from a clinician immediately.
NWAS gave evidence in writing that they had raised the concern and their suggested management with the National NHS Pathways team on 6 April 2023, with the result that the national team would continue to review the process but with clinical review in 15 minutes and high risk medications being upgraded to category 2. It is unclear from the evidence whether this is a proposed change to the process in place in September 2022 which would mean Mr Ackerley would have had a category 2 response at 21.48, or whether the system remains the same. If the system is not for a category 2 response for high risk medication, it is my concern that this will not allow for prompt treatment of those who have taken a potentially fatal overdose.