Nadeem Ahmed · Prevention of Future Deaths report

On 21st February 2020, I commenced an investigation into the death of Nadeem Ahmed. The investigation concluded at the end of the inquest on 16th June 2021. The conclusion of the inquest was a narrative conclusion:

Mr Ahmed died as a result of the traumatic exsanguination of his brachial artery. His death was contributed to by a failure to provide accurate and relevant clinical information to the HEMS team, through correct emergency call triaging. These failures denied Mr Ahmed the opportunity of receiving life saving treatment prior to his cardiac arrest.

Mr Ahmed lacerated his brachial artery when he put his hand through a glass pane in a door at his home address, on the 8 February 2020. Two calls were made to the London Ambulance Service and both calls were incorrectly triaged. The correct triage would have resulted in an earlier attendance of the first LAS unit, by around two minutes. On arrival of the emergency ambulance crew, Mr Ahmed had clear signs of hypovolaemic shock. There was a failure by a crew member to provide accurate and relevant clinical information to the HEMS team. Had relevant and accurate clinical information been provided, the HEMS team would have attended. They would have administered sedation; inserted a central line and administered blood products. Such clinical interventions, would on the balance of probabilities have prevented Mr Ahmed's death. The correct triaging of the 999 calls, would have provided an opportunity for the earlier attendance of the HEMS team. This would have increased the likelihood of successful lifesaving treatment. Mr Ahmed did not receive any bloods prior to his cardiac arrest. He arrested en route to the Royal London Hospital. Sadly, Mr Ahmed suffered multiple organ ischaemia and he passed away at the Royal London Hospital on the 13 February 2020

At the time of communication between the LAS paramedic on scene and the paramedic on the HEMS dispatch desk, Mr Ahmed was in a state of hypovolemic shock. He had a very high pulse rate, a very high respiratory rate, had suffered a brief loss of consciousness and had a concerning pallor. This clinical picture was not conveyed to the HEMS desk. The paramedic on scene did not offer accurate and relevant clinical information. The paramedic on the HEMS desk requested only the GCS and not the full clinical parameters.

There may be an opportunity to improve communication between the HEMS dispatcher and paramedics on scene, by joint training and/or provision of a check-list for key clinical parameters to be shared. A senior HEMS clinician gave evidence at the inquest. He stated that video link communication might also aid in the transfer of relevant and accurate clinical information.