Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0416, written 17 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2016 |
|---|---|
| Reference | 2016-0416 |
| Deceased | Brian Mills |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Community health care and emergency services related deaths |
| 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.
CORONER'S OFFICE AREA OF HERTFORDSHIRE The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES DX: 100702 Hatfield Tel: 01707 292780 Fax: 01707 897399 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Claims and Inquest Facilitator East of England Ambulance Service Hammond Road Bedford Bedfordshire MK41 ORG CORONER | am Geoffrey Sullivan, Senior Coroner for Hertfordshire 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. . http://www. legislation.gov. uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov. uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On the 26th January 2016 Brian Mills fell on the stairs at home sustaining multiple injuries including a number of broken ribs. An ambulance was called at 11:16 hours but a rapid response vehicle arrived at 13:23 hours. An ambulance arrived at 13:38 hours and conveyed Brian Mills to the Lister Hospital. He was deemed unsuitable for surgical intervention and treated conservatively with intravenous antibiotics and fluids. Brian Mills died at 11:15 hours on the 13th April 2016. | heard evidence from the treating doctor and the pathologist that the delay in the ambulance arriving did not, in this case, cause or contribute to the death. CIRCUMSTANCES OF THE DEATH Brian Mills was an 88yr old man on warfarin who had fallen and had a bleeding head wound who had to wait over two hours for an ambulance. On that day, the East of England Ambulance Service log revealed that the Bedford Emergency Operation Centre had a number of calls unassigned prior to and during the time the cail for Mr Mills had been received: 10:44hrs: eight outstanding emergency calls, longest waiting time of 1hr 52 minutes. 10:48hrs: thirteen outstanding emergency calls, longest waiting time of 3hr 7 minutes. 12:47hrs: twenty four outstanding emergency calls, longest waiting time 3hr 53 minutes. CORONER’S CONCERNS | heard evidence that this was not an unusual amount of outstanding calls or an unusual level of waiting time. This was the position on the 26" January 2016 and | heard evidence that this is still the position now. 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 MATTER OF CONCERN is as follows. — (1) Consistently high fevels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 12 January 2017. |, 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 sent a copy of my report to the Chief Coroner and to the following Interested Persons, land the East and North Hertfordshire Trust. | 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. | Dated 17 November 2016 Signature Senior Coroner for Hertfo
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.
East of England Ambulance Service NHS) NHS Trust . : Patient Services Department Our Reference: EE Bedford Locality Office Harnmond Road Bedford 11 January 2017 MK41 ORG Tel: (01234) 243320 Freephone: 0800 028 3382 Mr Geoffrey Sullivan Fax: (01234) 243083 Senior Coroner The Old Courthouse St Albans Road Hatfield AL10 0ES Dear Mr Sullivan | am writing further to your letter dated 17" November 2016, enclosing a Regulation 28 Report to Prevent Future Deaths. This report was made by you following the inquest into the death of Brian Douglas Mills, which concluded on 16" November 2017. You were concerned about the high levels of outstanding emergency calls that exceeded the NHS Response Times targets and recommended that action be taken to resolve this. All calls are triaged using an Advanced Medical Priority Dispatch System (AMPDS), which codes and then categorises the call. This standardised system ensures priority patients receive a response first. | understand that NS the Trust's Quality Improvement and Professional Standards Lead, wilt be delivering some training to Coroner's Officers around the country this year in relation to the coding and resourcing of 999 calls. All ambulance services, and the wider NHS system, are seeing a year-year rise in demand. To take the recent weeks as an example, activity has been 31% higher than the previous four weeks and in one 24 hour period we received more than 4,000 calls. We also experienced exceptional increases in the number of hours lost through handover delays at hospitals, at one point we had 60 ambulances queued at hospitals across the region. If our community teams are waiting at a hospital or attending other calls, it leads to a stack of Red calls and, depending on the number waiting, call handlers are instructed to provide most calls categorised as Green with a predicted response time. These are not response times that we would want or expect but are part of the increasing pressure on our system. A number of mitigating initiatives have been introduced led by the Trust Medical Director to protect patient safety during these periods of pressure when responses to Green patients are delayed. These include increasing the number of clinicians in the Emergency Operations Centres (EOC) to increase the number of patients treated over the phone and referred to appropriate pathways. Following consultation with hospital colleagues we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions. However, the good news is that the number of responses to our most seriously ill patients — the Red 1 category — within eight minutes is on a constant upward trend and we continue to respond to more patients more quickly than ever before. Chief Executive: Robert Morton In the context of ever growing demand, we also need to be clear that while we are taking every possible step we can, we do not have the capacity available to deliver national NHS Response Times Targets. in line with the Trust's strategic objective to improve service delivery to our patients, we are negotiating with regulators and commissioners on the funding required to meet the acknowledged capacity gap at EEAST. We continue to recruit hundreds of patient facing staff within the financial envelope provided which in the environment of increasing activity is the only sustainable solution to delayed responses to patients. Our Quality Strategy has recently been showcased and the Trust is in the process of implementing a revised operating model, which includes the introduction of a new clinical career pathway for our staff. This will help to develop our dedicated workforce and improve the clinical care we provide. | hope this information assures you that the Trust is taking action following the inquest into the death of Brian Mills and that we are continuing to seek improvement in the way we manage and respond to 999 Calls, Yours sincerely Lhe MA Robert Morton Chief Executive
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