Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0237, written 19 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2018 |
|---|---|
| Reference | 2018-0237 |
| Deceased | William Watson |
| Coroner | Andrew Cox |
| Coroner area | Cornwall & Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Cornwall Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS William George Irvin WATSON, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BE be puty Director of Urgent and Emergency Care, NHS Dorset Clinical Commissioning Group, Vespasian House, Barrack Road, Dorchester, Dorset, DT1 1TG 2. NHS Kernow Clinical Commissioning Group, The Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS 3. Copied to: CCG’s at foot of this letter CORONER | am Andrew Cox, Assistant Coroner for the coroner area of Cornwall & Isles of Scilly. 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. INVESTIGATION and INQUEST On 18 May 2017 an inquest was opened into the death of William George Irvin Watson who died on 11 May 2017 at the age of 82. | conducted the inquest on 20 June 2018. | found that Mr Watson died from: 1a) Pneumonia; 1b) Coronary Artery By-Pass Graft Surgery (post op) | recorded a Narrative Conclusion that Mr Watson died from complications of a necessary surgical procedure. CIRCUMSTANCES OF THE DEATH On 24/1/17, Mr Watson was admitted acutely into Royal Cornwall Hospital with worsening angina. Coronary angiogram revealed severe multi-vessel disease. On 20/2/17, he underwent a triple CABG at Derriford hospital. He suffered a number of post-operative complications including an infected sternal wound that necessitated further surgery. On 13/4/17 he was transferred from Derriford to Treliske. On 22/4/17, a CT chest revealed a potential collection around the sternum and it was feared Mr Watson’s wound had become re-infected. Arrangements were made to transfer him back to Derriford. There were a number of difficulties with that transfer. A clinician first contacted SWAST to arrange the transfer at 16:32. A response time of 40 minutes was indicated. At 18:09, following a deterioration in the patient's condition, the request was cancelled by which time an ambulance had not arrived. At 18:18 a doctor made a fresh request for an ambulance to effect a transfer to Derriford. A response time of one hour was indicated. An ambulance was allocated at 19:43 but three minutes later re-directed to a patient with a greater clinical need. At 20:25, a further ambulance was allocated but then again directed away. At 21:40 Mr Watson was re-classified as a Category 2 patient. An ambulance arrived on scene at 21:46 or nearly 2% hours after the target time. At inquest, | heard from Ms Merriott of SWAST. It was candidly accepted that the reason for the delay was due to demand in the area at the time. It was further accepted that this was not an isolated incident and that there was and is currently a lack of resources to meet the existing demand. On 3/5/17, Mr Watson was discharged from Derriford back to Treliske. Again, there were difficulties with the transfer. The initial request was made at 13:48. The staff member who took the call missed the fact that a technician was required and this was not recognised until a vehicle came to collect Mr Watson at 16:00. At that point the booking service was asked to arrange a High Dependency transport which was done through Lifestar. | was told they are the only provider available in Cornwall. Mr Watson was collected at approximately 17:00 but did not reach Treliske until 19:40 hours approximately. 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. — Emergency ambulance transport | asked to be shown, in confidence, the correspondence that has passed between the NHS Dorset CCG and SWAST touching on the current lack of resource. It is plain there is a recognised problem and that considerable efforts have been made, notably through changes in the rota, to close the gap between the resource that is required and that which is available. It is equally clear that a significant performance gap remains indeed, as | understand the position, it is accepted that minimum performance standards cannot be met under the current financial provision. The obvious implication is that where an adequate response cannot be made because of insufficient funding to resource the service appropriately, the consequent delays may result in lives being lost. These could be avoidable deaths. It is my duty, in such circumstances, to make this report to you. | would be pleased to know: - Howis the current financial shortfall to be remedied and by when? - By what date do you expect the minimum acceptable performance standards to be met? If a current constraint involves a lack of funding from central government | would be grateful if you would disclose to me, again in confidence, any relevant correspondence you may have had on the point. If it is necessary for me to do so, and | await your response, | will additionally direct this report to central government. High Dependency Transport | heard that the only provider of this service in Cornwall is Lifestar. | was informed that on occasions when Lifestar has no available resource it is necessary to contact providers from out of county. The evidence | heard from P| was that there was a definite gap in service provision. Given that this involves the transport of patients with a High Dependency there is again a real risk that fatalities may arise in the future. | would be pleased to learn whether it is accepted by NHS Kernow CCG that there is a gap in service provision currently. If so, please set out how it is proposed to fill that gap and by when. Non-emergency transfers | was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Ezec. | was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours. | was informed that these targets are not being met. The inquest was advised that a new service provider will be taking on this business from April 2019. Of great concern to me was the revelation made at inquest that there are currently no compliant bids. It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk. In such circumstances | would be pleased to learn what steps the commissioners propose to put in place to remedy the difficulties that exist currently and the foreseeable, additional risks that will arise from April next year if action is not taken beforehand. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. | would be pleased to hear from you in reply to the matters identified above. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 September 2018. 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Watson’s family, SWAST and RCHT. 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 response by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 19/07/2018 CC’d to: NHS Dorset Clinical Commissioning Group; NHS Bath and North East Somerset Clinical Commissioning Group; NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group; NHS Gloucestershire Clinical Commissioning Group; NHS Kernow Clinical Commissioning Group; NHS Northern, Eastern and Western Devon Clinical Commissioning Group; NHS Somerset Clinical Commissioning Group; NHS South Devon and Torbay Clinical Commissioning Group; NHS Swindon Clinical Commissioning Group; NHS Wiltshire Clinical Commissioning Group; NHS South, Central and West Clinical Commissioning Support Unit.
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.
NHS} ; Dorset Clinical Commissioning Group Vespasian House Mr Andrew J Cox Barrack Road Assistant Coroner for Cornwall & the Isles of Scilly Dorchester The New Lodge DT11TG Newquay Road Tel: 01305 368900 Penmount Fax: 01305 368947 Truro www.dorsetccg.nhs.uk TR4 9AA 13 September 2018 Dear Mr Cox Regulation 28 letter following the death of William Watson Thank you for your letter dated 19" July 2018 regarding the death of Mr William George Irvin Watson. | am writing to you as the co-ordinating commissioner for the South Western Ambulance Service NHS Foundation Trust (SWASFT) contract for emergency ambulance services, on behalf of the 10 CCGs in order to address the matters of concern. The specific details regarding this case regarding the High Dependency Transport and the Non-emergency transfers will be addressed directly by Kernow CCG as the commissioner of those services, therefore our response will focus on providing you with further details regarding the Emergency Ambulance transport contract that we collaboratively commission. During the Autumn of 2017 all ambulance trusts across the country implemented the Ambulance Response Programme (ARP), which has fundamentally changed the way in which ambulance response times, categorisation of calls and dispatching of vehicles are managed and monitored. In order to understand the full impact of ARP, SWASFT commissioned a piece of modelling work. The modelled resource gap to achieving the ARP standards currently states 241.7 whole Time Equivalent (WTE) or 15,147 vehicle hours per month, based upon 2017/18 contract activity level and the current resourcing and operational model. If this were to be addressed through a like-for-like operational model, there would need to be a recurrent revenue investment of £12m with associated capital cost of £4m. In accordance to your letter and the matters of concern raised, | will now respond to each of your questions in turn: How is the current financial shortfall to be remedied and by when? Supporting people in Dorset to lead healthier lives Following a round-table meeting held in February 2018 which was attended by SWASFT, Dorset CCG as Coordinating Commissioner, NHS England and NHS Improvement; a number of specific actions were addressed which has now led to the following developments. 1) A Joint Plan has been co-produced with commissioners and SWASFT which has a number of components in order to address the gap in performance. To summarise: a. SWASFT Performance Improvement Plan — set of actions owned at both executive and operational levels; b. STP (Sustainability Transformation Plan) Action Plan — Commissioner owned actions by all ten CCGs and regionally accountable to local STP and A&E/Urgent and Emergency Care (UEC) delivery boards; c. The Transition Plan - covering transformation and funding. As well as increasing resources, modernising the service model and identifying additional funding, one of the aims of the Joint Plan is to reduce the overall demand into the ambulance service, to ensure the right patients are receiving the right care in the right place and achieving the best outcomes. This may mean being treated in an alternative setting to the ambulance service. This will ensure the resource is available for those who need it, when they need it. The STP action plan responds to opportunity areas, identified by SWASFT, which require STP system partners to collaborate in order to support improved performance against ARP. All actions have been developed based upon local pilots and national evidence. The projected impact assumes and requires all actions are implemented across the entire SWASFT operational area. 2) A financial framework has been developed on the basis of the £12m funding gap as part of developing the Joint Plan and has been agreed by all 10 CCGs across the South West in August 2018. The framework sets out a 2.3% investment over 3 years, however recognising that for 2018/19 a maximum of only £1.774m can be made available, this requires a higher level of resource to be found for 2019/20 to balance the 2 years. 3) A fleet capital bid for £6.72m submitted by SWASFT to the Ambulance STP Capital Scheme Funding has been successful. This will provide an additional 63 vehicles and will be fully operational by 1 February 2019. In order for SWASFT to meet the treasury rules and to achieve the operational deadline, £1.32m would need to be forthcoming. The agreed financial framework now ensures that this non-recurrent vehicle set up cost will be made available as part of the £1.774m investment during 2018/19. The Financial Framework sets out a total overall investment of £13.8m by commissioners to support achievement of the ARP standards. By what date do you expect the minimum acceptable performance standards to be met? SWASFT have provided commissioners with a draft business case which sets out how the investment in the Trust’s A&E contract would be utilised to improve and deliver ARP performance standards. Based on the original analysis and recruitment profile, the trust would deliver the following ARP performance standards by the end of September 2020: e Category 1 Mean and 90th Percentile e Category 1 Transport Mean and 90th Percentile e Category 3 Mean and 90th Percentile e Category 4 Mean and 90th Percentile Category 2 Mean and 90th Percentile would be achieved in June 2021 when the paramedic recruitment is complete. The above timeline has been established on the basis of the performance model which was undertaken at a point in time in September 2017/18. We have agreed with SWASFT that this analysis will need to be revisited in quarter 2 of 2018/19 and this will be jointly commissioned by the Trust and the CCGs. It is anticipated that the revised output will lead to adjustments to the proposal contained within the business case. | trust this provides you with the detail requested and further assurance that significant work and developments have taken place. We continue to work collaboratively with the ambulance trust in order to address the gap in performance and ultimately improve response times for all patients. Yours sincerely, ae Deputy Director of Urgent and Emergency Care Dorset CCG Co-ordinating Ambulance Commissioner South West of England Urgent and Emergency Care Executive Lead for Cornwall and the Isles of Scilly
INHS Ey, YEARS S Kernow OF THE Nis Clinical Commissioning Group PRIVATE AND CONFIDENTIAL Chief Officer Sedgemoor Centre Mr Andrew Cox Priory Road Cornwall Coroners’ Service St Austell The New Lodge PL25 5AS Penmount Newquay Road Te: Truro Cornwall ena TR4 9AA 13" September 2018 Dear Mr Cox, Thank you for your regulation 28 report to prevent future deaths pertaining to Mr William George Irvin Watson. In your report you identify a number of concerns and the action to be taken by NHS Kernow as commissioners of high dependency and non-emergency transport services. The matters of concern relating to emergency ambulance transport will be addressed by Dorset CCG in a separate response. The matters of concern you have raised to be addressed by NHS Kernow and our response to them are as follows: High Dependency Transport You heard that the only provider of this service in Cornwall was Lifestar. You were also informed that on occasion when Lifestar has no available resource it is necessary to contact providers from out of county. You heard evidence that there was a definite gap in service and wished to learn if this was accepted by NHS Kernow. Currently NHS Kernow purchases high dependency transport on a non-contract basis therefore each transport is booked/purchased based on the needs of each person. This is arranged through the Centralised Booking Service based at Royal Cornwall Hospitals NHS Trust (RCHT), commissioned by NHS Kernow to ensure that all non-emergency patient transport is booked to suit the individual health care needs. 01726 627800 kceg.contactus@nhs.net Chief oficer www.kernowccg.nhs.uk Head office eoeoe°0 Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS /nhskernow There is more than one provider of this service. The predominant providers of high dependency transport are Lifestar Medical and First Care Ambulances. Lifestar are based in Cornwall, First Care is based in Exeter and provides a service across the South West. They also provide services to Northern Eastern and Western Devon Clinical Commissioning Group. High dependency transport is non-emergency and therefore planned; if extra capacity is required above and beyond the capacity of the two providers mentioned above then provision may be purchased from another provider out of county in order to meet that need. NHS Kernow therefore is not aware of any gap in commissioned service. Non-Emergency Transfers You were told at the inquest that the service commissioned by NHS Kernow was provided by E-zec. You were further advised that its performance targets were to collect 95% of people within one hour and for short notice bookings, 50% were collected within one hour and 95% within two hours. You were also informed that these targets were not being met. ’ You have also raised the concern that people who required this form of transfer were kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk. E-zec Medical Services is commissioned by NHS Kernow to provide non-emergency patient transport (NEPTs). This covers transport for a range of needs including outpatient appointments, transfers of care and discharges. NEPTs would only transfer someone in a very stable condition, for example a person transferred from an acute to a community hospital or their normal place of residence. We would not wish people to wait beyond the performance standards for many reasons. With a de-escalation of care or the movement of an individual from an area of high health care need to lower/no health care need, any deterioration in condition would be addressed, i.e. they would be waiting in the safest place and assessed. In the case of Mr Watson we would not expect E-zec Medical Services as our provider of non- emergency patient transport to convey a high dependency person as they are not commissioned to provide that service and would not have a clinically appropriate vehicle or staffing resource and, as a result, it would not be safe to do so. We would also not expect a person to be transferred from a specialist centre (Derriford) to another acute hospital unless the person was fit and safe to be transported, as this is a de- escalation of care. A delay in the high dependency transport arriving for the journey would not cause harm to the person as they would be in the most appropriate environment to meet their health care needs and able to access high quality care immediately if needed. If it was an escalation of care and the person’s condition was deteriorating then we would expect the person to be transferred in an emergency ambulance by the South West Ambulance Service Trust (SWAST). Page 2 For clarity the performance target refers to the window of collection from their agreed pick up time, not from the time of booking. This is for a standard booking. Enough time should be given by the hospital booking the transport to allow the transport provider to time to plan the journey. This should be done as soon as possible, preferably the day before it is required, Wherever possible the performance requirements within the E-Zec Medical services contract for standard bookings are: e 50% of service users to be collected at their agreed discharge/ready time up to 30 minutes after their identified ready time 90% of service users to be collected at their agreed discharge/ready time up to 45 minutes after their identified ready time e 95% service users to be collected at their agreed discharge/ready time up to 60 minutes after their identified ready time Our provider is currently performing at the following levels: e 56% year to date average against the 30 minute target of 50% e 73% year to date average against the 45 minute target of 90% (improved from 66% average in previous year) e 86% year to date average against the 60 minute target of 95% (improved from 74% average in previous year E-zec Medical Services has made significant improvements over the last 12 months and is currently on target to meet their trajectory of improvement in order to meet the required standards. NHS Kernow continues to work with the provider and the health system to ensure demand and capacity is manged in order to achieve these standards. Short Notice Bookings At the time of this case the performance measure for short notice bookings was 95% of journeys to be collected within two hours of booking. These targets have since been amended to meet the needs of the service and are currently: e 50% within two hours (provider currently achieving year to date average 55%) e 70% within three hours (provider currently achieving year to date average 75%) e 85% within four hours (provider currently achieving year to date average 87%) NHS Kernow is currently reviewing the definition of a short notice booking to ensure that it meets the needs of people. Page 3 Procurement The inquest was advised that a new service provider would be taking on the business from April 2019. Of great concern to you was the revelation made at inquest that there are currently no compliant bids. You would be pleased to learn what steps the commissioners propose to put in place to remedy the difficulties that exist currently and the foreseeable risk that will arise from April. NHS Kernow was undertaking a procurement exercise at the time of the inquest which was open to many potential bidders including incumbent providers. The procurement was closed on 27" June 2018. The procurement was subject to EU regulations and at the time of the inquest on 20" June 2018 no information had been released relating to the outcome. The procurement process was not successful in securing the universal non-emergency patient transport service we were trying to achieve so in order to mitigate future risk NHS Kernow has been working with our current providers who have agreed, in principle, to an extension of their current contracts. This will ensure that the current service that people receive will not be disrupted. The re-procurement is viewed by NHS Kernow as a potential opportunity to improve service provision and we are committed to achieving this. During this extension the CCG will finalise their future commissioning arrangements for one universal non-emergency patient transport service with the continued aim of meeting the needs of the population of Cornwall and the Isles of Scilly. Over the coming months NHS Kernow will be working with current and potential providers, stakeholders and the public in order to understand why the procurement exercise was unsuccessful and how we can improve going forward. | hope this action provides you with some comfort. Please do not hesitate to contact me if you require anything further in relation to this case. Yours sincerely PA, 4 Ve wt Lou Chief Officer Page 4
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