Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0199, written 26 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 May 2016 |
|---|---|
| Reference | 2016-0199 |
| Deceased | Peter Scott |
| Coroner | Heidi Connor |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. 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. Richard Henderson, Chief Executive, East Midlands Ambulance Service NHS Trust (‘EMAS’) 2. Simon Stevens, CEO, NHS England 3. NHS Hardwick CCG 4. Jim Mackey, CEO NHS Improvement 5. The Rt Hon Earl Howe, Dept of Health 1 CORONER I am Heidi Connor, assistant coroner for the coroner area of Nottinghamshire. 2 CORONER’S LEGAL POWERS I 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 25 February 2016, I commenced an investigation into the death of Peter Scott, aged 78. The investigation concluded at the end of the inquest on 18 May 2016. The conclusion of the inquest was natural causes. The medical cause of death was : 1a Hypovolaemic shock 1b Rupture of a dissection of the thoracic aorta 2 Ischaemic and hypertensive heart disease 4 CIRCUMSTANCES OF THE DEATH Mr Scott suffered an aortic dissection at home on 3 December 2015. Mr Scott had a pendant which he wore around his neck, and he and he used this to summon help via Nottingham City Homes (‘NCH’). NCH contacted EMAS at 01.34 hrs. EMAS was told that Mr Scott had fallen, was in pain, and was on the floor. The call was prioritised as Green 2, and as such, the target was to reach him within 30 minutes. In fact, the call was allocated to a double-crewed ambulance at 0342 hrs, and they arrived on scene at 0356 hrs. The arrival time was almost 5 times longer than the target time. We heard evidence that EMAS had invoked a Capacity Management Plan (‘CMP’) (level 4) at this time, and as such, lower priority calls (including this one) were taking longer to respond to. We also heard that NCH should have re-contacted EMAS between 11 and 15 minutes after the first call, to advise that Mr Scott had become unresponsive. EMAS evidence was that the call would then have been prioritised as Red1 or Red 2, with a target 1 response time of 8 minutes. Given the resource issues and CMP in place at that time, it is not possible to be certain when an ambulance would have arrived if the call had been re-prioritised. I found it unlikely, on the balance of probabilities, that earlier ambulance attendance would have changed the outcome for Mr Scott. 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 : I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016. We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months. The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period. I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue. Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals. I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only. 1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken. 2. Consideration should be given to strategies to improve handover times at hospitals. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 July 2016. I, the coroner, may extend the period. A response is expected from each of the recipients, although the coroner may accept a joint response from recipients 2 to 5, provided it is clear that all have agreed this. 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : 1. Family of Mr Scott I 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. 9 26 May 2016 H.Connor 3
4 responses 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.
NHS Trust Emergency Care | Urgent Care | We Care Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk 21 June 2016 Ms Heidi Connor HM Assistant Coroner Nottinghamshire Office and Main Court The Council House Old Market Square Nottingham NG1 2DT Dear Ms Connor Re: Report to Prevent Future Deaths: Peter Scott (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11" May 2016, bringing to my attention the Coroner's concerns arising from the inquest into the death of Peter Scott. | would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, any matters arising from Coroners Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group having considered all the relevant issues of concern relating to the particular inquest will develop an appropriate action plan with specified timelines and identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Death notice pertaining to the inquest into the death of Peter Scott. The MATTERS OF CONCERN are as follows: 1. (I consider) that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken. 2. Consideration should be given to strategies to improve handover times at hospitals. Taking the concerns in turn, | set out the actions we have taken and our response to HM Coroner’s concerns in the PFD notice. The Care Quality Commission report recognised that EMAS has been working really hard to improve response times to emergency calls. However there are concerns that ultimately relate to the lack of resource (staff and vehicles), made worse by the numbers often kept waiting at hospital, and lack of capacity to do things as quickly or as well as they should be. East Midlands Ambulance Service NHS) NHS Trust Emergency Care | Urgent Care | We Care EMAS has taken the CQC findings seriously and value the additional support from other NHS organisations following the CQC Quality Summit. With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS’ immediate control. Following extensive negotiations an agreement has been reached with all commissioners for the EMAS 2016/17 Accident and Emergency 999 contract. The final position is for a one year block contract with a value of £152.5 million. A key part of this year’s contract is the agreement to carry out an independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service. EMAS and the clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand. Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against a recruitment plan target of 342. However, a higher level of turnover was experienced compared to that forecast (11% against a target of 8%). EMAS continues to recruit to the frontline again this year. Through exit interviews, EMAS monitors the reason for staff leaving. From those interviews the top reasons are (in order of priority): 1. Lack of opportunity/career progression/further training 2. Work life balance 3. Better pay To address this, EMAS has produced a new People Strategy to develop and support our staff to be highly skilled, motivated, caring and compassionate professionals. Hospital handover is the time it takes Emergency Department staff to accept a clinical handover from ambulance crews, thereby releasing them to respond to other 999 calls (Note: national target for this is 15 minutes). Hospitals are not able to accept a prompt clinical handover when they are experiencing high demand or a large influx of patients arriving at the same time. The Care Quality Commission inspection at EMAS in November 2015 and findings published in May 2016 brought focus to the seriousness of the hospital handover delays experienced over the last year. Delays result in patients waiting on the back of ambulances, or in hospital corridors whilst their care is supervised by ambulance crews. While the ambulance supervision is being provided it prevents crews from being able to respond to new 999 calls that have been received. This means patients in the community experience a delay in response and this is of concern. The delays impact on staff wellbeing and morale because they can increase shift length and increase anxiety levels when crews know calls are waiting to be responded to, or when they know they will be first on scene having to explain a lengthy delay. They also impact on ambulance resourcing across the region, as vehicles and crews move across county boundaries to assist where there are delays. This takes crews away from their usual operating area and has a corresponding impact on the ability for the ambulance service to use resources efficiently. That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation. Actions taken by EMAS in particular at the LRI includes: East Midlands Ambulance Service NHS) NHS Trust Emergency Care | Urgent Care | We Care e Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays e Increased number of paramedics based at hospitals to support their teams with the triage of patients and flow through the department e Anew booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when delays are being experienced These measures have allowed progress and improvements to the average handover times; however there is still more work to do to ensure the improvements continue on a sustainable basis, and that there is a continued reduction in long waits. | would also like to make a comment with particular regard to the work that EMAS has undertaken with the acute hospitals in Nottinghamshire. Prior to March 2016 EMAS used a Radio Frequency Identity (RFID) system to record the hospital handover time cycle. The system required a small tag to be attached to the ambulance stretcher and the electronic patient report form Toughbook. When either device passed through the doors at Queens Medical Centre (QMC), Nottingham a record was generated which allowed for monthly statistics to be produced. RFID proved difficult to manage as the device had to be matched to a vehicle, should the stretcher or Toughbook be swapped onto another vehicle, the produced data could be erroneous. The data provided was not real time therefore delays could not be challenged at the time. Since March 2016 the QMC has engaged with EMAS to install Ambulance arrival screens. Unlike RFID which used electronic tags the ambulance arrivals screen uses a simple touchscreen interface based on a webpage. This new process provides real time data to both QMC and EMAS which allows both to see delays as they happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete. The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon. Illustration of QMC Arrival Screen East Midlands Ambulance Service ; Ambulance Arrivals Queens Medical Centre Campus Hospital 33 % 97.77 % 13 mins 10 mins 22.25 mi 2 3 8 Last Updated: 15:28 Call Number Callsign Type Call Received As Status Time/ETA Elpsd Pats Facility 29 8411 | EMG | 21D03 Dangerous Haemorrhage Notified 15:20, 8) 1 Emergency Dept 8916 | EMG | 30B01 Traumatic Injuri ssibly Dangerous Body Area | Notified 15:06) 22) 1| Emergency Dept 8420 EMG | DX0162 Transport to ED w/in 1 hr Handover 15:07 21 1) Emergency Dept Call Number Callsign Type Call Received As Status Time/ETA Elpsd Pats Facility 8375407 8913 EMG | 33IFT Priority 1 IFT transfer Inbound 0 Mi 1 mins 1 Emergency Dept 8375376 8419 | EI 1C0 Unconscious or Fain! ~ Alertwith Abnormal-Brea | Inbouhd 3 Mi 6 mins 1| Ethergency Dept 8375425 2412 8CO1 Headache and Not Alert Inbound 3 Mi 7 mins 1) Emergency Dept When delays are identified the Division will, where possible, allocate a Team Leader manager to act as a local Hospital Ambulance Liaison Officer (HALO). The role is to work with the hospital management team to ensure that ambulances are not delayed at hospital any more than necessary. East Midlands Ambulance Service INHS| NHS Trust Emergency Care | Urgent Care | We Care The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time. Since April 2015 Nottinghamshire Division has increased the available hours for both Double Crewed Ambulance (DCA) and solo Fast Response Vehicles (FRV). This is through the recruitment of staff and realignment of rosters to match increased demand. Table 1 Resourcing comparison April 2015 and April 2016 DCA Filled Hours FRV Filled Hours April 2015 34252 8606 April 2016 36487 9478 Increase 2235 872 Percentage Increase 6.52% 10.13% | trust that this has answered all of the issues from your Prevention of Future Deaths Notice, but please do not hesitate to contact me if there is further information which is required Yours sincerely Richard Henderson Acting Chief Executive
Hardwick Clinical Commissioning Group
CCG Headquarters
Scarsdale
Nightingale Close
Off Newbold Road
Chesterfield
Derbyshire
S41 7PF
Tel: 01246 514000
Fax: 01246 514166
BY EMAIL
5th July 2016
Ms Heidi Connor
Her Majesty’s Assistant Coroner
Nottinghamshire
Dear Ms Connor
Regulation 28: Report to Prevent Future Deaths in the case of Peter Scott
This letter sets out the response of NHS Hardwick Clinical Commissioning Group (CCG) to your
regulation 28 report dated 26th May 2016. You have raised the following point:
1. I consider that there is a risk of future deaths as set out above unless an urgent review of
resources is undertaken
I would like to assure you that Hardwick CCG, on behalf of the 22 CCGs across the East Midlands
region, works closely with East Midlands Ambulance Service (EMAS) NHS Trust to ensure that
they have sufficient resources to respond to patients in a timely manner.
Response
1. There is a risk of future deaths as set out above unless an urgent review of resources is
undertaken
Within the 2016/17 emergency ambulance contract CCGs have committed to undertake a jointly
commissioned external strategic review focussing on capacity and demand in order to support
delivery of an efficient ambulance service delivering performance across the region, with the
outputs from the review being implemented over a three year period.
There are a number of key outcomes expected from the strategic review:
An accurate analysis of current demand and capacity taking into account the issues
identified within the recent CQC notice
An analysis in relation to current operational efficiencies covering, but not limited to, skill
mix, fleet configuration and current delivery model
Identify the resource implications in terms of overall staffing and vehicles in order to deliver
against national performance targets. This analysis would also determine any increases in
staffing required to maintain performance and will detail the required front-line operational
roles, and quantities, to operate the model.
Chairman: Dr Steve Lloyd Chief Officer: Andy Gregory
As part of the 2016/17 emergency ambulance contract settlement, Commissioners have provided
additional funding to support EMAS to undertake further recruitment to increase their front-line
establishment in order to ensure resources are available to respond to emergencies in a timely
manner. The contract agreed is a block contract, which gives a year of financial certainty in relation
to income, to give EMAS the confidence and ability to implement the necessary changes to
delivering a timely response to all patients across the East Midlands.
The additional funding has enabled an expansion of the Clinical Assessment Team (CAT) who can
provide clinical support and telephone assessment to support the management of patients through
Hear & Treat where appropriate, thus releasing that resource to respond to patients with more
serious clinical need that require immediate treatment or transport.
The additional funding will also support an increase in the numbers of front-line staff, thus
increasing the resource available to respond to patients who require a face to face response.
Commissioners are actively working with EMAS and acute providers to reduce the number of
patients who are waiting to have pre-clinical handover, thus releasing crews to be available to
respond to other emergencies who require an ambulance response.
I trust this response addresses the point you have raised but I will be happy to discuss this further
should you require.
Yours sincerely
Andy Gregory
Chief Officer
Hardwick Clinical Commissioning Group
(On behalf of NHS Hardwick CCG as Coordinating Commissioner for East Midlands CCG’s)
Chairman: Dr Steve Lloyd Chief Officer: Andy Gregory
Heidi Connor Assistant Coroner for Nottinghamshire HM Coroner's Service The Council House Old Market Square Nottingham NG1 2DT Dear Ms Connor, INHS England Professor Sir Bruce Keogh National Medical Director Skipton House 80 London Road SE1 6LH RECEIVED 14 JUL 2016 KM IZ July 2016 Regulation 28: Report to prevent future deaths concerning the death of Peter Scott Thank you for your Section 28 report concerning the death of Mr Peter Scott. | would like to express to the Scott family my deep sympathy and sadness at the death of Mr Scott. Your report references the need to review the resources available to the East Midlands Ambulance Service NHS Trust (“EMAS”), and to consider strategies to improve handover times at hospitals. NHS England would like to make the following observations in response to the specific concerns you have raised at Section 5: 1. The need for an urgent review of resources to reduce the risk of future deaths The need to review the resources available to EMAS has been recognised locally. The responsible commissioners, NHS Hardwick — Clinical Commissioning Group (“CCG”), on behalf of 22 CCGs across the East Midlands, have committed to jointly undertake an external strategic review of capacity and demand with EMAS. The review, which was agreed as part of the 2016/17 contract between EMAS and CCG commissioners, will consider a wide range of issues including the current delivery model, staffing issues and vehicle numbers. It is expected that the strategic review will provide an accurate analysis of the current demand and capacity issues facing the service, and will address many of the findings of the recent Care Quality Commission (“CQC”) Quality Report into services provided by EMAS (published May 2016). The 2016/17 contract settlement also provided additional funding to EMAS in order to increase front-line staffing with the intention of improving ambulance response times. It is also intended that services should be further improved by an agreed expansion of the existing Clinical Assessment Team (“CAT”) as High quality care for all, now and for future generations treat a greater proportion of patients safely without conveying them to hospital. This will free up both ambulance service and emergency department resources. | trust that this response addresses the concerns you have raised. | am grateful to you for bringing these matters to my attention. | know that the commissioners of the service (the CCGs) and the regulator of the Trust (NHS Improvement) are working closely with the EMAS to help them to bring about further improvements. Yours sincerely, Professor Sir Brute Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: nhsi.enquiries@nhs.net W: improvement.nhs.uk 25th July 2016 Mrs Heidi Connor Assistant Coroner for Nottinghamshire Nottinghamshire Coroner's Service Organisation & Transformation The Council House Old Market Square Nottingham NG1 2DT Dear Mrs Connor REGULATION 28: REPORT TO PREVENT FUTURE DEATHS I refer to your email of 26 May in which you enclosed a Prevention of Future Deaths Report you issued following the death of Mr Peter Scott. I was very sorry to learn of the death of Mr Scott and the circumstances that led to it. NHS Improvement takes cases such as these very seriously and I would like to offer you the assurance that we are already working with the East Midlands Ambulance Service NHS Trust and other partner organisations to address the issue of resourcing and to improve response times to emergency calls. You may be aware that the Care Quality Commission published a report on 10 May 2016 which recognised that the trust has been working really hard to improve response times to emergency calls, however the report highlighted concerns that ultimately relate to the lack of resource, both staff and vehicles. The trust has already been taking steps to address the resourcing concerns. In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts. NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. In the Annex attached to this letter, I have set out the steps the trust is taking and continues to take in addressing the resourcing shortage and improving response times to emergency calls. Yours sincerely Jeffery Worrall Portfolio Director (Midlands & East) Enc. NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.
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