Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0126, written 22 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2022 |
|---|---|
| Reference | 2022-0126 |
| Deceased | John Murphy |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Emergency services related deaths (2019 onwards) |
| 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. Secretary of State for Health and Social Care
1
CORONER
I am Lauren Costello, Assistant Coroner, for the Coroner Area of Manchester South
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 12th July 2021 I commenced an investigation into the death of JOHN SCOTT
MURPHY then aged 46 years. The investigation concluded at the end of the
inquest on 21st April 2022. The conclusion of the inquest was natural causes.
The medical cause of death being
1a Covid-19 Pneumonitis
II Hypertensive Heart disease.
1
4
CIRCUMSTANCES OF THE DEATH
John Murphy tested positive for Covid-19 infection in the week before he died. His family
reported that he seemed to be improving although he was extremely fatigued. He lived
alone and was alone in his home when he started to deteriorate in the early hours of
Sunday 11th July 2021. At 03:20 he called the North West Ambulance Service and he
reported that he was breathing too fast. The Service were dealing with extremely high
demand at that time and had escalated its Patient Safety Plan response to Level 4, Tier 5.
Mr Murphy was categorised as a category 2 patient needing emergency care. An
ambulance arrived at his property at 05:21 and by that time he had passed away. A post-
mortem examination confirmed that he had undiagnosed hypertensive heart disease which
can be a risk factor for a poorer outcome with COVID 19.
A number of measures have been undertaken by the North West Ambulance to address
emergency response times including:
• Utilising the Voluntary Aid Service and private ambulance support,
• Ongoing recruitment, although it is acknowledged that this takes time,
• The introduction of a Clinical assessment of category 3 cases rather than
automatic ambulance allocation,
• Movement to NHS pathway tool from MPDS which changes the way Category 3
and 4 calls are managed again to reduce ambulance allocation.
Live waiting times in Greater Manchester during the Inquest hearing were on average at
34 minutes against a target of 18 minutes and in 9 out of 10 calls the response time was 1
hour 29 minutes against a target of 40 minutes.
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 could 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) Despite a number of measures being undertaken by the North West Ambulance
Service, the delay in paramedics attending Category 2 calls has not been resolved
to within target ranges because there are residual staff and emergency vehicle
shortages.
(2) The resources available in the North West Ambulance Service cannot be fully
utilised because of the delays in ambulances clearing Accident and Emergency
departments caused by the pressure on these departments across the NHS.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
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 23rd June 2022. 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
North West Ambulance Service
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
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.
9
DATE
SIGNED BY CORONER
22nd April 2022
3
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.
Ms Lauren Costello HM Assistant Coroner for Manchester South Coroner's Court 1 Mount Tabor Street Stockport •Department of Health & Social Care 2.}(,(I. November 2022 Dear Ms Costello, Thank you for your letter of 28 April 2022 to the then Secretary of State Sajid Javid, about the death of John Scott Murphy. I am replying as Minister with responsibility for Health and Secondary Care and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Murphy's death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. · In preparing this response, Departmental officials have made enquiries with NHS England, as well as the relevant regulator, the Care Quality Commission (CQC). There is work ongoing to address the concerns outlined in your report. The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care. Ambulance handover times are also a major part of the Greater Manchester Urgent and Emergency Care Improvement Plan for 2022/23. The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. Ambulance trusts receive continuous central monitoring and support from the NHS England funded National Ambulance Coordination Centre, and there is a range of support in place to In addition, NHS England has allocated £150 million of additional improve performance. system funding for ambulance service pressures in 2022/23, supporting improvements to response times through additional call handler recruitment, retention and other funding pressures. You may wish to know that we have also made significant investments in the ambulance workforce. The number of NHS ambulance and support staff has increased by 40% since February 2010, and Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service. The number of national 999 call handlers has also been boosted to over 2,300 at the start of May 2022, about 400 more than September 2021, with potential for services to increase capacity further during 2022/23. Additionally, a £1.3 million national campaign for the 999 call handlers was initiated in March to support trusts. This is alongside a £50 million national investment across NHS 111 in England for 2022/23 to support additional NHS 111 capacity to ensure people get the care they need when they need it and avoid unnecessary demand on ambulances. This builds on additional investment from last year. Finally, ambulance services across the country have been working closely with their local systems to reduce avoidable conveyance and support patients to get the care they need outside of hospital. Conveyance rates to Emergency Department are the lowest ever outside periods of national lockdown. To drive further progress and support regional and local system arrangements, we have established a national discharge taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow. We will continue exploring options that minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of support. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, WILL QUINCE MP MINISTER OF STATE FOR HEALTH
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