Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0149, written 20 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2016 |
|---|---|
| Reference | 2016-0149 |
| Deceased | Ronald Hamer |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Community health care and emergency services related deaths |
| Organisation named | Welsh Ambulance Services NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Welsh Ambulance Services NHS Trust — South East Area 2. Chief Coroner 3. Health Inspectorate Wales 4. Family — (Daughter) 5. — Minister for Health & Social Services 1 | CORONER | am Graeme Hughes, Assistant Coroner, for the coroner area of South Wales Central Area. 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 16" February 2016 | opened an inquest into the death of Ronald Hamer. | concluded that inquest on the 13" April 2016. The conclusion of the inquest was Accidental Death. oe | 4 | CIRCUMSTANCES OF THE DEATH The deceased was an independent elderly gentlemen living at his home at On the morning of the 8" February 2016 he slipped and fell in the | bathroom of his home sustaining an injury to his right arm. He became immobilised on | the floor remaining in an awkward position whereby his right arm was trapped by his body. This incident occurred around Sam and he was not discovered by his family until around 6:45pm - over 13% hours later. A call to the emergency services was made at around 6:50pm with the ambulance arriving shortly before 9:30pm. Mr Hamer was conveyed to Prince Charles Hospital in Merthyr Tydfil but despite treatment his condition deteriorated and he died there on the morning of the 10" February 2016. 5 | 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. — 1) As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes. It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again. 8 COPIES and PUBLICATION 2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call. A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1% hours after the original call had been received. 3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the at February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 15"" June 2016. 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. | | have sent a copy of my report to the Chief Coroner, The Welsh Ambulance Services | Trust, Health Inspectorate Wales, the family and the Minister for Health & Social | Services who may find it useful or of interest. | | lam 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 rs “ onse by the Chief Coroner. 20" April 2016 SIGNED:
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ymddiriedolaeth GIG Q G IG Gwasanaethau Ambiwlans Cymru Lj Welsh Ambulance Services 0 N H S WHS Trust Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol Regional Ambulance Headquarters and Clinical Contact Centre TY Vantage Point / Vantage Point House, Ty Coch Way, Cwmbran NP44 7HF rn ee www.ambulance.wales.nhs.uk CHAIR AND CHIEF EXECUTIVE'S OFFICE Your Ref: PS Fe Our Ref: 9 June 2016 PRIVATE AND CONFIDENTIAL Mr Graeme Hughes HM Assistant Coroner South Wales Central Area Coroner's Office 1% Floor, Rock Grounds Aberdare CF44 7AE Dear Mr Hughes Re Ronald Hamer (Deceased) | am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased). | would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the key actions for improvement. Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28. | can assure you that as a consequence of this case we have learned lessons as an Organisation which are being monitored through a Task and Finish Group of senior staff, led by the Director of Quality, Safety and Patient Experience. | would also like to assure you that the monitoring of the actions and agreed timescales will be scrutinised through the Trust Board Quality, Patient Experience and Safety Committee. In addition to the Regulation 28 requirements | would like to extend an invite to you to meet with the Director of Operations and the Medical Director who will be able to provide you with an overview of the new and pioneering Clinical Response Model and also the context of the events that were occurring across NHS Wales on the 8 February 2016. Cadeirydd/Cnair: Mick Gisnnasi Prt WeithtedwriChief Executive: Tracy Mybbi Mae'r Yinddinedoloeth yn croasawu gohepiactn yn y Gymraeg neu Ssesneg The Trust welcomes corospondence in Welsh or Enghst fe ttle, IVs suf = x ¢ sYYfr evs Please do not hesitate to contact me if you have any questions with regards to the action plan. Yours sincerely Jin Mbt Tracy Myhill Chief Executive Enc.
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