Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0175, written 15 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jun 2022 |
|---|---|
| Reference | 2022-0175 |
| Deceased | Keith Hopwood |
| Coroner | Alison Mutch |
| 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: Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater 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 30th September 2021 I commenced an investigation into the death of Keith Hopwood. The investigation concluded on the 17th May 2022 and the conclusion was one of: Narrative: Died from a myocardial infarction whilst awaiting the arrival of an ambulance. The medical cause of death was 1a) Myocardial Infarction; 1b) Stenotic Coronary Artery Atheroma; and II) Hypertension, Diabetes Mellitus 4 CIRCUMSTANCES OF THE DEATH On 29th September 2021 at 11:28 Keith Hopwood called an ambulance as he had fainted and felt very unwell. His call was assessed at a category 3. An ambulance was dispatched to his home address at 11:38. It was rerouted to a more urgent call at 11:43. At 12:50 Keith Hopwood was spoken to by a clinician. He reported chest pains and feeling very unwell. The call was suddenly disconnected. Mr Hopwood should have been upgraded to a category 2 but was not. A private ambulance under contract to NWAS was dispatched at 13:17 and arrived at 13:34 at his home address . Keith Hopwood was unresponsive and could not be resuscitated. Post mortem examination found he had died from a myocardial infarction due to stenotic coronary artery atheroma. 1 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 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. The inquest heard that the delays in relation to the ambulance service were due to significant resource issues for all ambulance services not just North West Ambulance Service. The inquest was told that the shortages were due to staffing levels and demand. Steps had been taken to try to increase resources but the ambulance service was still struggling to meet the demand. In this case it was clear that had the initial ambulance not have been rerouted due to demand and pressure on services that he would have been alive when he was seen and have been transported to hospital; 2. The inquest heard that in the initial call to the ambulance service he was told to call back if he got worse in any way. His response was to say that he couldn’t feel any worse than he had in the last 10 minutes. The algorithm driving the conversation did not direct that this response should require exploration of symptoms and why he had made this comment. As a consequence an opportunity to explore his presentation further was lost; 3. The ambulance that arrived was a private ambulance and not equipped to deal with a cardiac patient. If the second call had been correctly categorised it would not have been dispatched as private ambulances are deployed with less qualified staff to calls categorised as 3 and 4 due to a lack of NHS Ambulance resources. As a consequence a further ambulance had to be deployed to the scene when Mr Hopwood was found to be unresponsive; 4. The second call from Mr Hopwood disconnected. Because he was alone a disconnection does not automatically result in an escalation of a call. Had he been with someone who said he had become unresponsive that would have generated a different approach. 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 10th August 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 2 is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) on behalf of the family; 2) North West Ambulance Service, who may find it useful or of interest. 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. 9 Alison Mutch OBE HM Senior Coroner 15.06.22 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.
Alison Mutch HM Senior Coroner, Greater Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK13AG •Department of Health & Social Care December 2022 Dear Ms Mutch, C Thank you for your letter of 15 June 2022, to the Secretary of State for Health and Social Care, about the death of Mr Keith Hopwood. I am replying as Minister with responsibility for Health and Secondary Care and thank you for the additional time allowed. . I would like to begin by offering my deepest condolences to the family arid loved ones of Mr Hopwood. It is of course vital that we take learnings where they are identified to improve NHS care 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 and the Care Quality Commission (CQC). 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. There are a range of measures in place to improve performance. The NHS has set out a plan to substantially increase capacity and resilience this winter. NHS bed capacity will be increased by the equivalent of at least 7,000 general and acute beds, including a mix of new physical beds and expanding the use of innovative virtual wards to treat patients safely at home. Building on the NHS plan, Our Plan for Patients set out further urgent action, including £500 million for an Adult Social Care Discharge Fund, helping people get out of hospitals quickly, freeing up beds and reducing long waits in A&E. This is alongside work led by the National Discharge Taskforce to reduce delayed discharge across acute, mental health, and community care settings, working with social care partners to implement best practice In addition, NHS England has allocated £150 million of additional system funding for ambulance service pressures this year and £20 million to upgrade the ambulance fleet. NHS England is also providing targeted support to some of the hospitals facing the greatest delays in the handover of ambulance patients into the care of hospitals, helping them to identify short and longer-term interventions to improve delays and get ambulances swiftly back out on the road. This is alongside a new national Winter Improvement Collaborative programme to help other trusts identify the root causes of handover delays and implement best practice. Furthermore, ambulance trusts receive continuous central monitoring and support from the National Ambulance Coordination Centre, and all local systems are establishing 24/7 System Control Centres to better manage demand at a system level. (J 4 The NHS will also expand.falls response services right across the country, whjch will see local teams sent to help people who have fallen in their home or in care homes, rather than unnecessary trips to hospital. We have made significant investments in the ambulance workforce, and the number of NHS ambulance staff and support staff has increased by over 40% since August 2010. 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. St John Ambulance has also been contracted to deliver auxiliary ambulance services, providing national surge capacity of up to 5,000 hours per month to support the ambulance response during periods of increased pressure, allowing NHS ambulance crews to focus on responding to emergency calls. In addition, national 999 call handler numbers have been boosted to around 2,350, over 300 more than September 2021, with plans to increase further to 2,500 by December 2022, supported by a £1.3 million national recruitment campaign. This is alongside a £50 million national investment across NHS 111 in England for 2022/23, supporting additional NHS 111 capacity to ensure people get the care they need when they need it, avoiding unnecessary demand on ambulances. This builds on additional investment from last year. Finally, in 2020/21, £450 million was invested to upgrade A&E facilities in over 120 separate trusts, to boost capacity and reduce overcrowding helping to clear ambulance queues more quickly. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, C WILL QUINCE MP MINISTER OF STATE FOR HEALTH 0 5
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