Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0041, written 1 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Mar 2017 |
|---|---|
| Reference | 2017-0041 |
| Deceased | Ceriann Richards |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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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. Chief Executive of the Welsh Ambulance Service NHS Trust 2. Chief Executive of the Royal Gwent Hospital 3. Chief Executive of Neville Hall Hospital! 4, Minister of Health, Welsh Government 1 | CORONER | am Andrew Barkley. Senior Coroner. for the coroner area of South Wales 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 17" August 2016 | commenced an investigation into the death of Ceriann Richards. Investigation concluded at the end of the inquest on the 28" February 2017 The conclusion of the inquest was that of a “Narrative” conclusion which was Ceriann Richards died from the effects of Venlafaxine Toxicity, bul the circumstances in which she came to be affected by it, remains unclear 4 | CIRCUMSTANCES OF THE DEATH The deceased was found by her husband acutely unwell and suffering fits al their home address in the early hours of the 14" August 2016 The deceased’s husband telephoned for an ambulance at 03 52 hrs on the 14" August and despite further contact with the emergency services the first rapid response vehicle arrived on the scene at 06:21 hrs followed by an ambulance arriving at 06:52 hrs ~ a delay of 2% hours to be at the patients side and 3 hours to convey the patient from the scene to an acute hospital During the period of time between the initial call and the arrival of assistance the deceased suffered 5 fits/seizures Upon admission to hospital at the Prince Charles Hospital she passed away within several hours being declared deceased at 10 10 hrs on the 14" August 2016 A subsequent post mortem examination revealed that she had toxic levels of prescribed anti-depressant medication Venlafaxine in her post mortem blood at a concentration of greater than 50mg per litre which was termed by the Toxicologist as being ‘very high and consistent with a significant overdose of this drug. The generally accepted toxic effects of this drug are usually noted in concentrations greater than 1 mg per litre and associated with fatalities of greater than 7mg per litre The evidence revealed that the delay in the ambulance arriving al the scene did not cause or contribute to the death as the evidence showed that she was Itkely to have 5 | been suffering with the toxic effects of the drug prior to the ambulance being called “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. — [BRIEF SUMMARY OF MATTERS OF CONCERN} (1) The delay tn an ambulance being despatched to the home address of the deceased who was Clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals within the Aneurin Bevan University Health Board Areas which on that day for the Royal Gwent Hospital were of an average of 107 minutes up to a maximum of 279 minutes and for the Neville Hall Hospital with an average delay of 43 minutes and the longest delay of 93 minutes. The evidence revealed that the agreed “handover time” is 15 minutes. The evidence further revealed that since guidance was Issued in the spring of 2016 in relation to the handover from ambulance crews to hospital staff the position has worsened and in the order of 140 to 200 hours are lost each day equating to 10 to 20 vehicles being off road for the whole day across the Welsh Ambulance Trusts Area 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, th namely by 25° April 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 the family who may find tt useful or of interest | 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 “4 March 2017 SIGNED: Mr Andrew Bandey HM Senior Coroner
2 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.
Q G IG Bwrdd lech 3 yd Prifysgol ofGjm Aneurin Bevan 0 N HS University Health Board Our ref: Direct Line: PF 20 April 2017 Mr Andrew Barkley H M Senior Coroner Rock Grounds First Floor Aberdare CF44 7AE Dear Mr Barkley Re: Ceriann Richards (Deceased) I write further to the receipt of the Regulation 28 Report in respect of the Inquest heard into the death of the above named person. The ability to release ambulance crews in order to respond to community calls is Of paramount importance to the Health Board. We have taken a number of steps to address these issues and have ongoing work at present, ‘Breaking the Cycle’, which is focussing resources on processes to support the patient journey. As a Health Board we have implemented and reviewed a number of key processes. e An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives. The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing governance and assurance to the Board. e A Standard Operating Procedure has been implemented which supports bed management and site management teams in utilising all bed capacity across both Nevill Hall Hospital (NHH) and Royal Gwent Hospital (RGH) when ambulances are in danger of being held outside of our Emergency Departments (ED). This protocol was adopted by the Health Board’s Urgent Care Board and is part of the Health Board Escalation Process, which was reviewed and re written in preparation for winter 2016/2017. Pencadlys Head quarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ff6n: 01633 234234 Tel No: 01633 234234 Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board Mr Andrew Barkley 2 20 April 2017 e The Health Board has identified escalation protocols which are used to guide ED staff in the operational procedures for receiving and off-loading ambulances. These include a preparatory escalation when more than three crews are on site and limited capacity exists to off load further ambulances, predicted to arrive. This escalation is to the bed management teams who are required to move patients from ED to the available bed capacity with immediate effect. e The Health Board has a Red Release Protocol for response to Welsh Ambulance Services NHS Trust (WAST) when a crew is required to attend a ‘Red’ call in the community. This protocol has been worked through with WAST colleagues who meet with Health Board Operational Managers each fortnight to discuss operational issues and address any concerns. e The Health Board has a Winter Resilience Plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. This plan is shared with all local stakeholders and partners to ensure the actions and initiatives described within the plan are shared and agreed prior to implementation. The Health Board has continually reviewed the plan on a month by month basis at its Urgent Care Board. This has led to a number of actions being reinforced since the implementation of the plan to ensure a more robust response to ambulance handover pressures. The following data clearly illustrates the impact that the escalation processes and protocols have had on reducing ambulance hand over times and delays >1hr at the Health Board this winter. NOV-DEC JAN - MAR AMBULANCE HOURS 7 LOST __2016/17 1178 — 2014 2015/16 1183 3002 % CHANGE -1% -33% AMBULANCE DELAYED > 1HR 2016/17 412 739 2015/16 443 1133 % CHANGE -7% -35% _ Since 23 March 2017, Aneurin Bevan University Health Board has been introducing ‘Breaking the Cycle’, an initiative which is looking at processes to support flow within the acute hospitals, ie timely discharge, appropriate placement and timely transfer of patients from the ED and MAU. Mr Andrew Barkley 3 20 April 2017 This has seen the implementation of two transfer teams, one transferring out of the wards and one transferring out of ED. Discharge facilitators have also been introduced on each of the wards at RGH. There is work is commencing to implement this model in NHH. Breaking the Cycle has led to improved patient flow within the hospital, reduced congestion in our EDs and has led toa consistent approach over seven days a week. The actions implemented by the Health Board have been captured in the attached action plan. Please be assured that these actions and their impact on ambulance handover performance are monitored by the Health Board. I do hope that this information and the action plan attached (developed in partnership with WAST) give the assurance that we, as a Health Board, are focussed on the patient flow and are actively working, in partnership, to reduce ambulance delays in our Emergency Departments and Assessment Units, to ensure that our citizens receive a timely appropriate response in the community. Yours sincerely usurp Judith Paget Prif Weithredwr/Chief Executive
Professor Dirprwy Brif Swyddog Meddygol Deputy Chief Medical Officer Eich cyf/ Your ref:AB/CE/ Andrew Barkley Senior Coroner South Wales Central Area Rock Grounds First Floor Aberdare CF44 7AE Dear Mr Barkley, 24 April 2017 Regulation 28 Report to Prevent Future Deaths – Ceriann Richards Thank you for your letter to the Minister for Social Services and Public Health regarding the regulation 28 report following your investigation into the death of Ceriann Richards. I am responding on behalf of the Minister. I would also ask that you please pass on our condolences to the family of Mrs Richards. You raised concerns regarding significant hand over delays within two district hospitals in the Aneurin Bevan University Health Board areas, resulting in the delay of an ambulance being dispatched. We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service’s ability to respond to subsequent calls in the community, but also on patient’s experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital, improving patient flow through the hospital system and enabling greater capacity in the community to support timely discharge. The Welsh Ambulance Services NHS Trust has made progress in limiting conveyance rates to hospital through the development of a five-step ambulance patient care pathway and focus on initiatives that help patients who have dialled ‘999’ to remain at home or to access a more appropriate service for their needs. This has included: the enhancement of its clinical desk, where paramedics and nurses provide secondary triage to patients who may be safely discharged over the telephone or advised to make their own way to hospital (known as ‘hear and treat’); establishment of alternative pathways for a number of conditions; a falls response service; and a frequent callers project which has significantly reduced unnecessary call demand Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ Ffon/Tel: 029 2082 3911 Ebost/Email:PSChiefMedicalOfficer@wales.gsi.gov.uk The NHS Wales Ambulance Availability Protocol, published in March 2016 is also subject to review by the Emergency Ambulance Services Committee (EASC) in light of concern raised in relation to its effectiveness. The Welsh Ambulance Services NHS Trust (WAST) and local health boards have shared responsibility for ensuring the safe and timely handover of patients from ambulance crews to hospital teams and I expect health boards and WAST to continue to work together to reduce handover delays and to divert demand around the system during busy periods as well as improving patient flow through hospitals Yours sincerely PROFESSOR
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