East Midlands Ambulance Service has clarified its protocol on when medics should stop trying to resuscitate patients after a woman’s death at a Nottingham mental health unit helped highlight a potential weakness.
Ambulance crews were called to the Wells Road Centre, Mapperley, when staff found 36-year-old Dipa Rameshchnadra Lad unconscious on March 4 2016.
Ms Lad had been diagnosed with paranoid schizophrenia and was detained at the centre under the Mental Health Act following a previous criminal conviction.
She died despite more than 20 minutes of resuscitation efforts by staff and ambulance medics, and an investigation into the circumstances of her death was opened four days later by Heidi Connor, HM assistant coroner for Nottinghamshire.
The conclusion of the inquest was held in public on January 24 this year. It delivered a conclusion of death by accident.
The medical cause of death was given as ligature pressure to the neck, which Ms Lad had inflicted on herself.
Notts TV did not attend the hearing, but has since been made aware of a ‘Regulation 28’ report Mrs Connor sent to East Midlands Ambulance Service (EMAS) listing seven key ‘matters of concern’ she said the service should address to prevent any risk of future deaths.
The report, published on the Ministry of Justice website, shows Mrs Connor ruled evidence heard at the inquest showed nothing EMAS crews did could have saved Ms Lad’s life.
But it describes how the hearing highlighted a potential problem with the protocol on resuscitation.
It said in the circumstances surrounding Ms Lad’s case, medics could stop providing life support and declare someone dead after less than 20 minutes of what is called ‘Advanced Life Suppport’ or ALS techniques – if staff thought their efforts were ‘futile’.
The coroner said this appeared to go against national guidance saying ALS should be continued in similar incidents for at least 20 minutes before someone can be declared dead, and that more clarity was needed on when staff could consider it ‘futile’ to attempt to resuscitate someone.
Mrs Connor also described how one of the ambulance technicians gave chest compressions standing up, with both feet either side of Ms Lad, instead of kneeling down beside her.
“The reason she gave for this was not wanting to get blood from the scene on her trousers,” Mrs Connor wrote.
“She was not in a confined space and, and when challenged by a team leader subsequently, used a towel to protect her clothes and continued to give compressions kneeling down.
“I am concerned to ensure that staff are trained/reminded of the best technique to give effective compressions – for the patient and for staff resilience reasons.”
EMAS has since written to the coroner with its formal response, the deadline for which was Wednesday (March 28).
The service has now added extra guidance on ‘futility’ and CPR into its protocol to clarify the policy for staff and reassure the coroner and patients.
In a statement, EMAS’s medical director Dr Bob Winter said: “We would like to express our sincere condolences to Ms Lad’s family for their sad loss. A verdict of accidental death was made at the inquest and the coroner made no link to our care being a contributory factor.
“Whilst the coroner raised concerns about our diagnosis of death policy, we would like to reassure the public that lessons have been learned from this incident and we have since updated our policy to provide additional support and guidance to frontline staff.”
When asked about the technician’s CPR technique, a spokesman for the service added: “All clinical staff are trained in delivering effective chest compressions and undergo an annual statutory and mandatory refresher training course which includes updates and an assessment on resuscitation in one of our education centres.
“No action was taken against the staff member, their CPR was judged to be effective, however kneeling CPR is always preferred and performing CPR stood up can cause a back injury.”
The Wells Road Centre is run by Nottinghamshire Healthcare, an NHS foundation trust.
A trust spokesman said: “Nottinghamshire Healthcare offers its sincere condolences to the family of Dipa Lad who died whilst in the care of the Wells Road Centre in Nottingham.
“This was a very complicated case and the coroner’s summing up reflected this. The coroner acknowledged the care and compassion evident in trust staff’s depositions and was assured by our efforts to learn from this tragic event.
“We have taken on board all of the recommendations and have indeed completed a comprehensive review of the care provided. Whilst we continue to try and make our services safer, on this occasion we do not think that Dipa’s death was predictable or preventable.”
