“S are as follows: I heard evidence that the Ambulance Service had replaced their…”

The coroner’s concerns

S are as follows: I heard evidence that the Ambulance Service had replaced their paper-based Patient Report Form with an electronic system, many years previously. The electronic Patient Report Form (‘ePRF’) is an important template which records all of the prehospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department. The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment. At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information. I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF but instead to rely upon the verbal handover alone. In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening. I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system. I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution. While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre. Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE Your organisations might wish to work together to provide a joint response to this report, and such would not only be acceptable, but encouraged. You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 July 2021. I, the coroner, may extend the period.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0312

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0