Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0216, written 17 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2022 |
|---|---|
| Reference | 2022-0216 |
| Deceased | Ronald Hartley |
| 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: The 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 25th November 2021 I commenced an investigation into the death of Ronald Hartley. The investigation concluded on the 13th June 2022 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Frailty; 1b) Fractured Neck of Femur (Operated on); 1c) Fall 4 CIRCUMSTANCES OF THE DEATH Ronald Hartley had an accidental fall in the garden at his home address. He was taken to Stepping Hill Hospital by his son after they were told the wait for an ambulance would be about 6 hours. At Stepping Hill Hospital, he was found to have a fractured neck of femur. He was subsequently operated on. Post operatively he initially recovered well, but then deteriorated which led to him becoming increasingly frail. On 22nd November 2021, he died at Stepping Hill Hospital. 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. 1 The MATTERS OF CONCERN are as follows. – The evidence to the Inquest from the family was that when they found Mr Hartley and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr Hartley to hospital. He had fallen in his garden in November. The family were faced with a choice of waiting with him for 6 hours when he clearly needed to be in hospital or transporting him to hospital themselves. Given his distress and their concerns about the impact of the prolonged wait on him they decided to transport him to hospital in their own vehicle. The Inquest was told that this was extremely difficult and caused significant pain and discomfort to Mr Hartley. 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 11th September 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely who may find it useful or of interest. on behalf of the Family, 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 17.07.2022 2
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.
From Will Quince Minister of State for Health and Secondary Care Alison Mutch Senior Coroner The Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, 21st December 2022 Thank you for your letter of 17 July 2022 about the death of Ronald Hartley. I am replying as Minister with responsibility for Health and Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Hartley’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 it is facing, ensuring that people receive the treatment that they need when they need it. This will be supported by the government investing an additional £3.3 billion 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 set out detailed recovery plans in the new year. In the short-term, ahead of this winter, the NHS is substantially increasing capacity and resilience. 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. Addressing ambulance handover delays is 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. 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. During this year NHS ambulance trusts have been supported with NHS England allocating £150 million of additional system funding for ambulance service pressures , supporting through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet. improvements to response times The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by over 40% since September 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 HEALTH
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