Pin
Get email alerts
Request correction
Investigation and inquest
On 12th April 2019 HM Senior Coroner commenced an investigation into the death of Mitica Marin. The investigation concluded at the end of the inquest before me on 12th March 2020. I arrived at a narrative conclusion;
“Mr Mitica Marin was found unresponsive at home on the evening of 11th April 2019, despite emergency medical assistance he could not be resuscitated and his death was declared at 21.03 hrs. in hospital. It has not been possible to determine the cause of his cardiac arrest.”
The medical cause of death was: 1a Unascertained
Circumstances of the death
Mr. Marin, 35, was found prone and unresponsive at home. The London Ambulance Service (“LAS”) was called at 19.06 and arrived promptly at the scene at 19.12.
On arrival, Paramedic A noted that CPR was not being performed. Cardiac arrest was confirmed, further resources were dispatched and resuscitation procedures were commenced.
After over an hour of advanced life support, at 20.31hrs, Mr. Marin was taken to hospital by ambulance, where his life was pronounced extinct at 21.03hrs.
Despite a post mortem examination and a toxicological screen, the cause of death was unascertained.
Coroner’s concerns
The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
Information checked against the published report and official responses