Mr Paul Mclean · Prevention of Future Deaths report

On the 19th October 2018 an inquest was opened in to the death of Mr Paul Mclean. The investigation concluded at the end of the inquest on 18th October 2019. The conclusion of the inquest was a Narrative: “Our conclusion as to the death of Mr Paul Mclean, was due to misadventure. It’s probable that taking synthetic cannabinoids led to status epilepticus which then further led to deterioration in health at Princess of Wales Hospital. On a balance of probabilities, to which the miss-categorisation of the call emergency services at 22:18am on 22nd July 2018, contributed to the delay in commencement of paramedic intervention/treatment. We believe that the delay contributed to prolonged status epilepticus. We believe that the prolonged stay in hospital prolonged agitation and development of pneumonia and sepsis in October 2018 and his death on 9th October 2018 was contributed to by his prolonged status epilepticus on 22nd July 2018.”

I attach a copy of the record of the record of inquest setting out the circumstances of Mr Mclean’s death as recorded by the jury.

Whilst the inquest initially focused on a number of wider issues relating to the death of Mr Mclean, what became the issue at its core, was the appropriateness of the categorisation of the initial call to the Welsh Ambulance Service (WAST) at around 10:18 on the 22nd of July 2018.

In particular, the series of questions posed by the call handler, and the responses thereto, which led to the initial code red colouring being downgraded to an amber one categorisation. This meant that an anticipated 15-20 minute emergency response (due to the location of the available crew to the incident scene), became around 80 minutes. The jury found that this extended response time, contributed to prolonged status epilepticus, and his subsequent death.

1. The adequacy/accuracy of the scripting of questions for seizure/fitting calls. In particular, and in relation to code 12D02 calls (post 19.6.19) the requirement for a healthcare professional to call back after 20 minutes of continuous fitting to trigger a call upgrade from Amber 1 to Red.

In an email from ████████ of 17.10.19 @ 07.11 and read to the court, it was confirmed that the question is not currently asked of the caller to WAST, how long has the patient been fitting?

This would appear to be a crucial piece of information in order to ascertain as accurately as possible, the known timing of the onset of the fit, for the purposes of determining when the 20minutes has elapsed. E.g. if it is known that the patient has already been fitting for 10 minutes, then the advice to call back should be in 10 minutes hence. If the fit has just commenced, then obviously, that advice can be for a 20 minute call back.

2. The wider issue of whether a response from a healthcare professional (to a question(s) posed by a call handler) that the patient is not maintaining his/her airways should in itself trigger/categorise a continuous red code. The evidence of ████████ at the Inquest, was that such a scenario was of the highest clinical priority, as the patient had a high risk of cardiac arrest in such circumstances. There appeared some tension in the evidence surrounding the 12D01/02/03 categorisation as to which code would be triggered on the volunteering, or otherwise of this indication from the caller.

3. Whether a pathway exists, or should be created for updating G4S – the operators of Parcison with changes implemented by the WAST affecting call prioritisation. This is likely to have the benefit of ensuring that healthcare professionals at the prison are fully aware of what is expected of them in an emergency call to WAST and what response can be expected from WAST at the time an emergency call is placed.

4. Whether there is, or should exist, a clear pathway for dialogue between the Princess of Wales Hospital Emergency Department clinicians and WAST in relation to best practice for call categorisation. In particular, whether there should be regular input from the emergency department consultants at the Princess of Wales Hospital into the CPAS group for the purposes of assisting in relation to the appropriate categorisation of calls.