STEPHEN ANTHONY BEDFORD · Prevention of Future Deaths report

On 2 August 2012 I commenced an investigation into the death of Stephen Anthony BEDFORD, aged 33. The investigation concluded at the end of the Inquest on 11 July 2013. The Conclusion of the inquest, handed down on 31 October 2013, was that:

Stephen Anthony Bedford died from a Natural Cause namely:
1a Acute Myocardial Ischaemia
1b Coronary Artery Thrombosis
The outcome might have been different had he been transferred in a more timely manner to the nearby Specialist Coronary Intervention Centre

Stephen Bedford aged 33 years had a past medical history of Type 1 Diabetes Mellitus and hypercholesterolemia. On 31.7.12 he experienced central chest pain whilst at a gym. En route home he attended Eaton Socon Health Centre where he collapsed at about 1600 hrs. An ambulance was called and he was conveyed to Bedford Hospital A&E where he was diagnosed with an ST elevation myocardial infarction. The same ambulance crew then conveyed him to Papworth Hospital via PPCI arriving at 1805 hrs with a history that he had arrested en route. Despite intervention death was confirmed at 1940 hrs the same day.

(1) Whether the Trust’s Emergency Care Assistants (ECA) and Emergency Medical Technicians (EMT) are assessed at intervals to ensure compliance with Basic Life Support(BLS) and Immediate Life Support (ILS) standards and scope of practice.
(2) Whether the Trust’s paramedics or otherwise only those with Advanced Life Support (ALS) training should be mandated to attend all Code Red ambulance transfers of patients diagnosed with acute coronary syndrome(ACS)
(3) Whether at the point of community referral (patient’s home, GP surgery or elsewhere) the referring individual or team are made aware by the ambulance crew of the scope of their training(i.e. BLS, ILS or ALS) to ensure an informed and optimal decision on transfer is taken.
4. Whether the Trusts paramedics, or only those with current ALS training should be mandated to attend all transfers post-activation of the Trusts Primary Percutaneous Coronary Intervention protocol ( Eo PPCI), as stipulated in that protocol.
5. Whether the Trust’s ECA and EMT crews should be made familiar with and instructed to adhere to the EoE PPCI protocol following any PPCI referral from the community or hospital and whether practical guidance in support of the protocol should be given on the lines suggested in the appendix attached.
6. Whether ECA’s and EMT’s should be provided with additional training and instruction on the full operation and interpretation of ECG machines and whether they should attend the Trust’s ILS Courses.
7. Whether contact with and continuing dialogue with relatives should be the subject of specific guidance once next of kin details have been established,