Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0195, written 24 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 | 24 Jun 2022 |
|---|---|
| Reference | 2022-0195 |
| Deceased | Grenville Wait |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | North West Ambulance Service NHS Trust |
| 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
THIS REPORT IS BEING SENT TO: 1). Sajid Javid MP, Secretary of State for Health and Social Care
CORONER
I am Chris Morris, Area Coroner for Greater Manchester (South).
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 3rd February 2022, I opened an inquest into the death of Grenville Wait who died on 6th
November 2021 at home, aged 83 years. The investigation concluded with an inquest which I heard
on 22nd June 2022, and which concluded that Mr Wait had died as the consequence of an accident.
CIRCUMSTANCES OF THE DEATH
Mr Wait fell whilst out shopping on 2nd November 2021. He was taken to hospital where a fractured
sternum was diagnosed. Mr Wait was discharged home with advice about taking regular analgesia
and a plan to follow-up with a fracture clinic appointment.
On 6th November 2021, a family member found Mr Wait deeply unconscious in bed with altered
breathing. A 999 call was made, and an emergency ambulance dispatched by way of a category 2
response, the call having been incorrectly coded as a category 2 rather than a category 1 call.
The ambulance arrived around 70 minutes after the time of the original 999 call, outside of the
target range for category 2 calls.
Around the time of the ambulance crew’s arrival, Mr Wait went into cardiac arrest and could not be
resuscitated. A post mortem examination determined Mr Wait died as a consequence of:-
1a) Pneumonia on background of fractured sternum
2) Ischaemic heart disease.
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 MATTER OF CONCERN is as follows. –
1) Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken
via its patient safety plan to manage and respond to demands on its service, it is a matter of
concern that target response times are still routinely not being met nationally. By way of
illustration, the court heard evidence that on 21st June 2021, the Trust’s average response
time for a category 2 call was 50 minutes with the response time to 90% of all relevant
incidents of 1 hour and 48 minutes.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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, namely by
19th 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 is proposed
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to
on behalf of the family.
I have sent a copy of my report to the Care Quality Commission, 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.
Dated:
24th June 2022
Signature: Chris Morris HM
Area Coroner, Manchester South.
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.
1 I, Chris Morris Area Coroner for Greater Manchester (South) · Coroner's Court 1 Mount Tabor Street Stockport SK13AG •Department of Health & Social Care December 2022 Dear Mr Morris, Thank you for your letter of 24 June 2022 to the then Secretary of State, the Rt Hon Sajid Javid, about the death of Grenville Wait. I am replying as Minister with responsibility for Health and Secondary Care and thank you for the additional time to respond. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Wai(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 and the Care Quality Commission (CQC). The Government is committed to supporting the ambulance service to manage the pressures i_t is facing, ensuring that people receive the treatment that they need when they need it. A range of measures are in place to improve ambulance performance. This will be supported by the government investing an additional £3.3 bilfion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will also set out detailed recovery plans in the new year, including plans to improve ambulance response times and improve A&E waiting times. The NHS has set out a plan to substantially increase capacity and resilience this winter. Bed capacity will be increased by the equivalent of at least 7,000 general and acute beds, alongside a £500 million Adult Social Care Discharge Fund, helping improve patient flow through hospital and reduce long waits in handing ambulance patients to A&E, getting ambulances swiftly back on the road. Further winter actions include establishing 24/7 System Control Centres in all local systems to better manage demand at a system level, and expanding falls response services right across the country, which will see local teams sent to help people who have fallen in their home or in care homes, rather than unnecessary trips to hospital. Addressing ambulance handover delays is also a key priority. NHS England is 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. NHS England has allocated £150 million of additional system funding for ambulance service pressures in 2022/23, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet. The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by almost 40% since April 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. I hope this response is helpful and you are assured that we will continue to work with the NHS to ensure the ambulance service has the support it needs to deliver for patients, both through winter pressures and beyond. Thank you for bringing these concerns to my attention. Yours sincerely, WILL QUINCE MP MINISTER OF STATE FOR HEAL TH
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