Monica Elaine Lewis-Hinds · Prevention of Future Deaths report

On 26th January 2015 I commenced an investigation into the death of Monica Elaine Lewis-Hinds. The investigation concluded at the end of the inquest on 11th February 2016. The medical cause of death was asphyxia due to epileptic seizure. The conclusion of the inquest was a narrative conclusion: that Ms Lewis Hinds suffered a seizure at home some time after midnight on 16th January 2015. An ambulance was requested at 0028 whilst she was in a distressed post-ictal phase. She suffered a further seizure some time after 0128 which led to asphyxia, cardiac arrest, and death.

Ms Lewis-Hinds suffered from poorly controlled epilepsy. An ambulance was requested to attend her home just after midnight on 16th January 2015 as she had suffered a seizure. The seizure was atypical, something which raises the priority of the call to Red 2 ( response time of 8 minutes). The type of seizure was not ascertained by the call handler, resulting in a delayed response. It was not possible to ascertain whether the delay caused or contributed to the fatal outcome.

The protocol used by the London Ambulance Service for triage calls includes a question about the type of fit, but the question is not posed by the call handler to the caller, and the section is only completed if the caller offers the information. In view of the potential consequences for the patient, this part of the protocol may require amendment, so that the question is put pre-emptively in all cases.