Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0020, written 4 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2020 |
|---|---|
| Reference | 2020-0020 |
| Deceased | Gordon Gillott |
| Coroner | Emma Serrano |
| Coroner area | Derby and Derbyshire |
| Category | Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. East Midlands Ambulance Service; 2. Chief Coroner; 3. Chesterfield Royal Hospital; 4. Royal Derby Hospital; and 5. Family of the deceased. 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of the Derby and Derbyshire. 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 On the 29th August 2018, I commenced an investigation into the death of Mr Gordon Gillottt. The investigation concluded with a Form B being issued by me. The cause of death after post mortem was: 1a Septicaemia; 1b Necrotic perforated non-reducible left inguinal scrotal bowel hernia; and II Chronic Obstructive Pulmonary Disease and left common iliac aneurysm (operated) 4 CIRCUMSTANCES OF THE DEATH i) Mr Gillott presented at Chesterfield Royal Hospital on the 8 August 2018 with a ruptured abdominal aneurism. He was transferred to the Royal Derby Hospital for repair of this. He initially survived the surgery but sadly passed away due to sepsis, secondary to a bowel perforation, not related to the surgery he received. ii) During the course of my investigation I received a letter from the Consultant General and Vascular Surgeon who completed Mr Gillott’s surgery. This highlighted Mr Gillott’s Transfer to the Royal derby Hospital was delayed substantially. It took over 2 hours for an ambulance to attend for the transfer. Multiple calls were made to the East Midlands Ambulance Service both by emergency staff at the Chesterfield Royal Hospital and the operating Consultant himself. The importance of the rapid transfer was emphasised on each occasion. On one occasion it was stressed that Mr Gillott would die if he was not transferred urgently. iii) Enquiries revealed the initial call requesting transfer was made to the East Midlands Ambulance Service at 05:28. This transfer was assigned at 06:59. Ambulance arrival at Chesterfield Royal Hospital for transfer was at 07:22. 1 [IL1: PROTECT] iv) The Consultant Surgeon has said that whilst he does not believe that the delay contributed to Mr Gillott’s death, he has significant concerns that such a delay could be repeated and, under different circumstances, might in fact impact upon patient care, up to and including death of a patient. v) East Midlands Ambulance Service have responded with a report. This states that the call was received at 05:28 and was classified as a Category 2 call. This required conveying a resource to arrive with the patient within 18 minutes. Resourcing issues meant that the ambulance was allocated at 6:59 and arrived at Chesterfield Royal Hospital at 07:22. The report details that the call was processed correctly and that dispatch actions were correctly with staff repeatedly looking for conveyancing resources. vi) The delay in response time was due to resourcing issues. 5 CORONER’S CONCERNS During the course of my investigation my inquiries 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. Whilst this delay did not affect Mr Gillott, were this to happen again in the future, there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues. 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 31 March 2020. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. The family of the deceased; 2. Chesterfield Royal Hospital; and 3. Royal Derby Hospital. 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. 2 [IL1: PROTECT] 9 4 February 2020 Miss Emma Serrano Assistant Coroner Derby and Derbyshire Coroners Area 3 [IL1: PROTECT]
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.
03 APR 2026
East Midlands
Ambulance Service
NHS Trust
Trust Headquarters
1 Horizon Place
Mellors Way
Nottingham Business Park
Nottingham:
NG8 6PY
PALS telephone: 0333 012 4216
Head office telephone: 0115 884 5000
Website: www.emas.nhs.uk
13 March 2020
_ Confidential
Ms E Serrano
‘HM Assistant Coroner
Coroner Office
Town Hall
Rose Hill
Chesterfield
$40 1LP
Dear Ms Serrano
Regulation 28 — Prevention of Future Deaths report regarding the case of
Mr Gordon Gillott deceased
Thank you for your letter of 4 February 2020 and the accompanying report into the
death of Mr Gordon Gillott. . ;
Unfortunately, no correspondence was received by East Midlands Ambulance Service
reference concerns raised by the General and Vascular Surgeon at the Royal Derby
Hospital until we were contacted by the coroner's office. If we had been contacted
we would have supplied the hospital and your office. with information regarding
transfers between Chesterfield and Derby Hospitals and their time frames in which
East Midlands Ambulance Service responded to them over the past 12 months. We
would have also given you the information regarding the new national procedure for
all requests for transport between hospital sites which commenced on the 1 October
2019. We are pleased to be able’to provide you with this information now.
Respond | Develop | Collaborate
|
- The PFD we have received raises a-concern that an ambulance was not dispatched
within the Category 2 response standard of 18 minutes on average and responding to
90% of Category 2 calls in 40 minutes. Whilst it is acknowledged that this did not
impact on the outcome in this case, there is a concern regarding patient impact of
future delays.
When Chesterfield Royal Hospital requested a transfer to the Royal Derby Hospital,
East Midlands Ambulance Service was in Capacity Management Plan CMP, level three.
The Capacity Management Plan (CMP) is designed to manage demand and resources
‘during high periods of demand, where the supply of normal ambulance service
resources is insufficient or potentially insufficient to meet the clinical demand of
patients. The aim of the CMP actions is to maximise responses to the most seriously
unwell patients. There are four levels of CMP as set out in the table below.
Neral No Issues ‘business as usual’
40 calls of any trigger category being er OCs ComcandeT Commander /
held
Regional
ae Tactical Commander /
Trust Strategic
Commander ,
Trust Strategic
Commander/ Executive on
call ,
55 calls of any trigger category being
held
| Regional
Prolonged period of demand (not
spike) or more than 70 calls being
held ,
Initiated when: a major incident is
declared and all other actions -have
failed to mitigate the circumstances
Regional
CEO/Exec on call & lead
commissioner
Regional
The delay for the transfer on this occasion was due to higher than anticipated levels
of 999 calls (in particular those in the highest priority category) and the impact of
hospital handover delays. EMAS must respond to emergencies with the same call
prioritisation code in time order for example; category two calls within 19 minutes
with a 90% percentile of 40 minutes, this includes whether they are in the community
or in a hospital environment.
At the time of Mr Gillott’s call the trust was in CMP 3 holding over 70 CMP qualifying
calls. The handover delays at the two hospitals involved in the care of Mr Gillott
between the hours of 19:00hrs on 7 August and 07:00hrs on 8 August are stated
below with 460 ambulances attending the hospitals within this time frame.
Respond | Develop | Collaborate
2
Chesterfield Royal Hospital -.19:00hrs 07/08/18 to 07:00hrs on the 08/08/2018
Handover times in minutes. The nationally agreed handover time is 15 minutes.
15+ 20 + Ee 45 + 30-59 |'? hours’
minutes minutes minutes minutes minutes ;
132 | 20° 16 1 ; 16 0
ambulances | ambulances | ambulances | ambulance | ambulance | ambulance
| Derby Royal Hospital - 19:00hrs 07/08/18 to 07:00hrs on the 08/08/2018
Handover times in minutes. The nationally agreed handover time is 15 minutes.
‘15 +, ; 20+ 30+ 45 + 30-59 1 -2 hours
minutes minutes . minutes minutes minutes :
186 128 40 13 “36 5
ambulance . | ambulance
ambulances | ambulances ‘| ambulances | ambulance
The above delays resulted in 34 lost hours of operational response availability,
impacting on our ability to attend patients in a timely manner. : ‘
EMAS implemented the new national Health Care Professional Admissions and Inter-
Facility Transfers Framework on the 1 October 2019. We have included the National
Framework for interfacility Transfers document for your information. : ;
Inter-facility transfers must be from an approved site; transfers requested from other
sites will be treated as health care professional admissions. Before the introduction of
the new procedure all requests from hospitals were a priority one response based on
-the category 2 timeframe. The introduction of the new procedure ensures that the
correct response standard is obtained and dispatched accordingly. The patient
awaiting transfer must be ready to leave for their destination within 15 minutes of
the transport arriving. Unfortunately we routinely experience delays on arrival which
leads to further delays in transfer of patients.
On the day of Mr Gillott’s transfer the division had already completed four transfers
from Chesterfield Royal Hospital. Other Trusts have introduced their own IFT
transport platform to avoid prolonged waits when the ambulance service is
experiencing high demand. ;
From the introduction of the new procedure EMAS have responded to the following
transfers from Chesterfield to Derby as below and their average timeframes are
shown below.
Respond | Develop | Collaborate
3
Month Pickup Hospital Hospital Total Crew waiting Mean
Name IFT CAT time for Response
2 patient to be
ready to leave
October | Chesterfield Royal 00:20:44 =| 00:40:27
2019 Royal Hospital | Derby -
- Hospital
November | Chesterfield — Royal 00:25:18 00:39:50
2019 Royal Hospital | Derby
Hospital . : ‘
December | Chesterfield Royal 00:26:21 00:29:32
2018 Royal Hospital | Derby
Hospital
January Chesterfield Royal 00:29:54 00:34:25
2020 Royal Hospital | Derby
Hospital
We continue to monitor performance and take action to improve our operational
_Tesponse. | have enclosed a copy of a table outlining the actions we are taking,
including those that are in collaboration with system partners
| hope that the information provided satisfies the questions you have raised and
demonstrates the changes that have been implemented to improve IFT responses.
I can only apologise to the vascular surgeon ‘that we did not provide the transfer in a
timely manner and we are more than happ
_ hospital if they have any future concerns.
Please do not hesitate to contact me further if you require any other assistance in this
matter.
Yours sincerely
Richard Henderson
Chief Executive
Encs
Respond | Develop | Collaborate
4
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