Clive Turner

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW

1 | CORONER

lam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East
and Central)]

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3. | INVESTIGATION and INQUEST

On the 28th of March 2014 | commenced an investigation into the death of Clive Harold
Turner (DOB 12.11.40, DOD 26.03.2014). The investigation concluded at the end of the
inquest on the 4"" of September and | recorded an narrative conclusion in respect of the
death in the following terms :-

At around 16.00 hours on the 25" March 2014 a call was made from the home of Clive
Harold Turner to the Welsh Ambulance Service NHS Trust requiring medical assistance
for him.

Due to the lack of available resources a First Responder did not attend until 1 hour and
27 minutes after the initial call. The First Responder assessed Mr Turner as requiring
admission to hospital and requested assistance. No ambulances became available to
provide this assistance until 21.30 hours, this being 5 hours 30 minutes after the initial
999 call and more than an hour after the First Responder had advised control that Mr
Turner was at the limit with the amount of morphine given.

The ambulance arrived at the Maelor Hospital Wrexham at 21.53 hours, however there
was a further 2 hour delay in his handover to nursing staff at 23.44, 8 hours and 45
minutes after the original 999 call.

Following examination at the emergency department he was incorrectly diagnosed as
being constipated and was discharged in the early hours of the 26" of March 2014
arriving home at 03.00 hours. He subsequently was verified as life extinct at his home at
13.24 on that same date as a result of a Gastro Intestinal Haemorrhage due to
Ischaemic Bowel as a result of Atherosclerosis.

4 | CIRCUMSTANCES OF THE DEATH

The Circumstances of the death are as set out in the narrative conclusion appearing in
paragraph 3 hereof.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows :-

Thats 10 in Emergency Medicine indicated in her evidence as follows :-

1. that she did not know what pain relief had been provided to Mr Turner by the
Welsh Ambulance Service

2. that she was not aware of any policies within BCUHB relating to the discharge of
patients overnight.

3. that there were no senior clinicians on duty from whom she could seek a second
opinion due to the lateness of the hour when she was attending to Mr Turner.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisations have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7" November 2014 I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have se y report to the Chief Coroner and to the following Interested
Person — (Son of the deceased) (partner of the Deceased)

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

[DATE] 12" September 2014 [SIGNED BY CORONER]

fp FAT

Ymddiriedolaeth GIG
Gwasanaethau Ambiwlans Cymru

Welsh Ambulance Services
NHS Trust

Q

LY £4
20)

=
>
m
wn

las

~ Péncadlys yr Ymddiriedolaeth, Safle H M Stanley, Llanelwy, Sir Ddinbych LL17 ORS
Trust Headquarters, H M Stanley Site, St Asaph, Denbighshire LL17 ORS
Tel/Ff6n 01745 532900 Fax/Ffacs 01745 532901
www.ambulance.wales.nhs.uk

6 November 2014

Mr John A Gittins

HM Senior Coroner.
H M Coroner's Office
County Hall

Wynnstay Road
Ruthin

LL15 1YN

Dear Mr Gittins,

Re: Report for the Prevention of Future Deaths
Inquest of Mr. Clive Harold Turner

We are writing in response to your Report pursuant to Regulation 28 of the Coroners
(Investigations) Regulations 2013, dated 12 September 2014.

This letter aims to confirm the actions taken by the Betsi Cadwaladr University Health Board
(BCUHB) and the Welsh Ambulance Services NHS Trust (the Trust) in accordance with the
three matters of concerns raised in your report (Regulation 28 notification).

1. That there were significant delays in the provision of assistance to Mr Turner by the
Welsh Ambulance Service

This first concern requires a retrospective summary of the delayed response, to ensure that the
Trust learn lessons from the sequence of events (SOE) relating to the 999 call made from the
home of Mr. Clive Harold Turner on the 25 March 2014 at 16.01 hours.

the Trust’s review of the SOE shows that the call was prioritised as requiring a face to face
assessment within 30 minutes. This category of call is set by the National Ambulance
Performance Standards, and is defined as a ‘Green 1’ call. It was quickly identified; however,
there were no resources available to attend at that time.

The contact centre staff, therefore, took a number of mitigating actions to continue to manage
the call. These included: continuing to search their technological system for any available
resources to attend the home of Mr Turner; the contact centre staff remaining on the telephone
line with the caller until the arrival of the first Paramedic; referring the call to the Trust’s Nursing
colleagues in NHS Direct Wales (NHSDW) for secondary clinical triage and advice; and,
ultimately sending the first available resource that was able to attend the home of Mr. Turner.

The SOE also revealed that throughout the time this call was being managed, delays in handing
patients over to Emergency Departments from ambulance crews were being experienced

ee Cadeirydd/Chair; Mick Giannasi
= V/s & W/E Prit Weithredwr Dros Dro/lInterim Chief Execullve: Tracy Myhil
Ci x &

o +: .

YW 2

Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg

san The Trust welcomes correspondence in Welsh or English

across the North Wales geographical area. For example, at the Wrexham Maelor Hospital,
where Mr. Turner was conveyed to by the Trust, the average Patient Handover delay during this
period was 164 minutes.

The mitigating actions of the contact centre staff are acknowledged as attempts to offset the
delay in responding to the home of Mr. Turner, and that their effort to gain extra clinical
assistance from NHSDW is to be commended. This action failed, however, due to the telephone
line being engaged, as the ambulance contact centre staff were still using the telephone to keep
in contact with the caller.

To prevent this break down in communication in the future, the Trust has developed a clear
process for escalating calls where a delayed face to face assessment (i.e. ambulance
response) is offset by gaining additional clinical assistance from NHSDW, who can undertake a
telephone assessment in the absence of an ambulance response. This will be in place from 1
December 2014.

Paragraph 3 indentifies further actions the Trust has taken to mitigate reoccurrence.

2. That the current practices in place for the handover of patients at an Emergency
Department far too often results in wholly unacceptable delays with patients being
kept waiting for long periods in ambulances and ambulance resources consequently
being unavailable for allocation to other calls. Whilst this is a multi-factorial problem,
improvements must be made so as to reduce the risk of future deaths.

BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance
handover across North Wales. The Medical Director has mandated the protocol that is currently
used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim
period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols
are currently out for consultation and will require ratification by both BCUHB and the Trust prior
to formal implementation.

The audit of ambulance handover to provide assurance in relation to patient safety during this
period of care has been revised by the BCUHB Associate Medical Director for Unscheduled
Care. The new process has been piloted at one of the Emergency Departments in North Wales
and following some amendment will be implemented across BCUHB and reported monthly.
This has already commenced in Ysbyty Glan Clwyd.

Holding areas are being established in each Emergency Department when required to enable
patients to be offloaded in a safe and timely manner. Serious Incidents where there are joint
issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared.
Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the
Health Board to ensure robust support for the Emergency Departments and patient flow.

BCUHB has developed an escalation protocol for their area to ensure a consistent approach
across North Wales. The protocol is currently out for consultation and will require ratification by
the North Wales Unscheduled Care Programme Board prior to implementation. This has
included advice issued by the Medical Director to support and encourage NHS Managers and
Clinicians to work closely with the Trust staff at the Emergency Departments (ED) “front doors”
to jointly assess patients held in ambulances and identify patients that could either safely be
transferred to the waiting room or be brought into the department without delay.

nN

There is engagement at all levels between the Trust and BCUHB, with conference calls
arranged to agree joint action plans to address ongoing delays. Duty Control Managers from the
Trust will initially contact the Hospital Clinical Site Managers if ambulances are delayed. The
escalation process will continue with the Trusts Locality Managers contacting the Senior Site
Operational Managers in BCUHB and then the Trusts Head of Service engaging with the Chief
Operating Officer within BCUHB Out of hours as there is an ‘On Call" system Bronze to Bronze,
Silver to Silver and Gold to Gold engagement between both organisations to ensure that a
seamless escalation process exists.

3. It is of considerable concern to me that item 2 above is a direct repeat of a concern
which | raised in a previous Regulation 28 report following the death of Mr Frederick
Pring in March 2013, twelve months before that of Mr Turner, the joint response of the
Trust and BCUHB being received exactly one week before Mr Turner’s death.

We would like to take this opportunity to provide you with assurance that BCUHB and the Trust
are committed to working together to deal safely and effectively when there are circumstances
of patients experiencing delays during handover. In addition, there are a number of
improvements and initiatives that have been implemented between both organisations since the
death of Mr. Pring. The following points provide more detail of these actions:

Alternative Transport

An initiative to promote alternative transport to convey low acuity patients to hospital has been
implemented. It has been identified that there are a number of low acuity patients that are
Clinically safe and suitable to travel to hospital by alternative means, either with family, friends
or in a taxi. The aim is to ensure that the Trusts resources are more readily available to attend
immediately life-threatening calls. This practice was implemented in North Wales on 1
September 2014.

Paramedic Pathfinder

Paramedic Pathfinder is a field guide (decision tool) to support on-scene decision making in
relation to the most appropriate point of care for the patient. This is being tested in Conwy and
Denbighshire since September 2014. The testing involves developing and_ introducing
alternative care pathways to provide patients with the treatment and care they need, and
thereby, potentially reducing the number of patients needing to be transported to Emergency
Departments. Paramedic Pathfinder will be implemented in the remaining localities of North
Wales during the next three months.

Rest Breaks for Trust Staff
the Trust further updated its Rest Break Policy in August 2014 to facilitate staff taking their
breaks at the nearest suitable location. These locations include base stations, other ambulance

stations, stand-by points or NHS locations which has fully functioning canteen/catering facilities
(e.g. at hospitals).

This change has resulted in a reduction in the time that resources are unavailable due to stand
down rest breaks, in turn improving the level of time that on duty crews are available to be
tasked with calls. Staff are now more likely to get their break in a timely manner and
arrangements are still in place in all three District General Hospitals to utilise its facilities in
support of mandatory breaks

Improvement to Call Prioritisation
Like many other UK ambulance services, the Trust uses the international accredited Medical
Priority Dispatch System (MPDS). This is a unified system for consistent call handling of

4

3

emergency calls, with the outcome being a priority code assigned for an appropriate ambulance
(or other clinical) response.

To ensure the Trust sustains and delivers best practice when utilising MPDS, the dispatch
codes in Wales have recently been reviewed. Subsequently, the Trust has now aligned its
prioritisation of the codes to the other UK ambulance services that also use MPDS._ This
enables the Trust to benchmark with other services, and at all times ensures patient safety.

The changes have further reinforced the Trusts desire to provide a more clinically effective and
appropriate service, and have been in place since 21 October 2014.

Clinical Desk

The Trust is introducing a Clinical Desk into the Clinical Contact Centre in Vantage Point
House, Cwmbran, which will be in operation for the whole of Wales. This will comprise of
Paramedics and Nurses providing further early triage of calls using the Manchester Triage
System to ensure the correct and most appropriate response is sent to meet the clinical needs
of the patient. This will be implemented by the Trust in December 2014 and provides:

¢ Clinical support for patients who are waiting for a response to arrive in excess of 8
minutes, especially those challenged by geography or access;

e Application of the product by Paramedics and Nurses:

e Clinical support for Clinical Contact Centres and responder colleagues.

¢ A potential improvement on the A8 performance standard of 1.5% — 2% by reducing the
number of Category A calls by at least 10 per day, this figure could increase dependent
upon the category of codes received on a daily basis;

e A clinical screening of Category A and Green 1 calls for secondary triage following
MPDS assessment.

In conclusion, we hope that this joint response from BCUHB provides you with the assurances
you require in response to the content of your Regulation 28 letter dated 12 September 2014.
Both organisations are committed to learn lessons from this difficult case and ensure that
patient outcomes are improved with more effective clinical care without delays. The necessary
improvements are being implemented as quickly as possible, and both organisations will
continue to monitor these actions as a part of their assurance/performance management
arrangements. This will include Board level review of progress reports.

Please contact us if any of this report is unclear, or if there are still areas of concern. We
commit to keep you informed of progress with respect to the key initiatives occurring in North
Wales as well as those with an all Wales impact. Thank you once again for your letter regarding
these very important issues.

Mates treke Jay My

Matthew K Makin MA MD FRCP (Edin) Tracy Myhill
Executive Medical Director Chief Executive (Interim)