Daniel Robert Ludlam · Prevention of Future Deaths report

On 6th January 2020 I commenced an investigation into the death of Daniel Robert Ludlam, 49. The investigation concluded at the end of the inquest on 26th May 2022. The conclusion of the inquest was death due to natural causes, contributed to by neglect.

Daniel Ludlam had a history of moderate learning disability and had a package of care in place. Daniel had a hiatus hernia and despite hospital attendances earlier in the year presenting with gastrointestinal symptoms, this had not been investigated thoroughly. As a result, the severity of his underlying gastric condition was not known.

On the 30th December 2019, Daniel complained of gastrointestinal symptoms of abdominal pain, haematemesis and melena. There was an initial delay in an ambulance being requested by his carers.

During the initial call to the emergency services, Daniel had been too unwell to speak with the call handler on the telephone. He was in bed and the land line telephone was in another room.

It was clearly stated to the call handler by the carer that due to Daniel’s learning disability, he may answer the questions with the response that he thought the questioner would want to hear, and that he may not answer the question accurately for that reason. Further, that he may not understand the question being asked. The carers assisted the call handler with relaying responses to the triage questions. The triage category allocated was Category 3 on the NHS Pathways triage system, with a response time of up to 2 hours. There was then a second call due to worsening symptoms and a further triage. The same information was relayed to a second call handler, that Daniel would not be able to answer the questions accurately due to his learning disability. The category remained at C3.

There was a delay in paramedic arrival at the property, due to the Surge Level the service faced at the time. Further backup paramedic support was immediately required as Daniel’s condition had deteriorated significantly. The category was changed to C2 and then C1. Despite the intervention of the paramedics, Daniel died at the scene. Post-mortem examination has identified that the hiatus hernia had been obstructed and caused a gastrointestinal haemorrhage which resulted in hypovolemic shock which was the medical cause of Daniel's death.

(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.

(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.

(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.