Patient deaths prompt ambulance chiefs to look for alternative defibrillators

London Ambulance Service Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy.

Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting.

The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later.

The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion.

But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered.

Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays.

In a letter to Mr Irvine, LAS chief executive Garrett Emmerson said changing the defibrillators’ default setting could result in more confusion as paramedics would likely mistakenly switch it to manual mode when they start it up. The trust also felt that changing them to automatic mode by default may not be “overtly practical for day-to-day use”.

Instead, he said a series of other actions have been taken, including putting warning stickers on the defibrillators and staff refresher training on how to use the machines. The trust is also investigating procuring new defibrillators.

But Mr Emmerson added: “Efforts are being made to investigate devices which have in-built technology to potentially bypass the need for a clinician to have to remember to put the device in [automatic] mode (for example, a device that would automatically switch the device… when the defibrillator pads are applied). At this point in time, we have not located a specific device on the market with this functionality which is sufficiently robust for the ambulance market.”

A spokesman for the LAS said: “Since 2017, training and guidance for our staff for using LP15 defibrillators has stipulated that they should be operated from the outset in automatic mode to reduce the risk of delayed defibrillation to patients. This is now standard procedure and reflects wider changes in practise for clinicians working in what can be a stressful and fast-moving situation.”

Physio-Control, the manufacturer of the LP15 defibrillator device, was mentioned in Mr Marin’s prevention of future deaths report. The company was acquired by medical technology firm Stryker in February 2016. Stryker did not wish to comment.

Martin Flaherty, managing director of the Association of Ambulance Chief Executives, said: “Although manual defibrillation should be the preferred option for appropriately trained paramedics it should be recognised that solo responders are potentially in a stressful environment, and are attempting to manage multiple complex factors.”