Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0264, written 26 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Aug 2022 |
|---|---|
| Reference | 2022-0264 |
| Deceased | Barbara Hollis |
| Coroner | Jaqueline Lake |
| Coroner area | Norfolk |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | East of England Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive East of England Ambulance Service NHS Trust Whiting Way Melbourn Cambridgeshire SG8 6EN 1 CORONER I am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK 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 04 March 2022 I commenced an investigation into the death of Barbara HOLLIS aged 71. The investigation concluded at the end of the inquest on 24 August 2022. The medical cause of death was: 1a Fat Embolism 1b Left Total Knee Replacement Operation 2 Acute Myocardial Infarction The conclusion of the inquest was that: Mrs Hollis died from a rare but recognised risk of an elective operation 4 CIRCUMSTANCES OF THE DEATH Mrs Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications. After her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 hours and were told that immediate clinical intervention was needed. The agreed hospital to hospital transfer pathway was not followed. A two hour delay in ambulance attendance was notified. Mrs Hollis continued to deteriorate and the ambulance service was telephoned again at 21.17 hours. The ambulance attended at 21.27 hours and Mrs Hollis was taken to the High Dependency Unit at the Norfolk and Norwich University Hospital. Her condition continued to deteriorate Regulation 28 – After Inquest Document Template Updated 30/07/2021 and Mrs Hollis died in the early hours of the 23 February 2022. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) 1. EEAST were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect. 2. The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes 3. At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours 4. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service 5. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 October 20, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Spire Healthcare I have also sent it to Regulation 28 – After Inquest Document Template Updated 30/07/2021 Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS England & NHS Improvement who may find it useful or of interest. 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. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 07/10/2022 Jacqueline LAKE Senior Coroner for Norfolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
INHS| East of England Ambulance Service NHS Trust Ms Jacqueline Lake East of England Ambulance Senior Coroner for Norfolk Service NHS Trust PC Whiting Way Melbourn Cambridgeshire 20 October 2022 SG8 6NA Dear Ms Lake Inquest into the death of Barbara Hollis lam writing further to the inquest into the death of Barbara Hollis, which took place on 24 August 2022, and the concerns you raised in relation to the delay in EEAST attending. | understand that Chris Hewetson gave evidence in relation to the steps the Trust was taking to manage the current call demand and you have requested a further review to establish if further steps should be taken in respect of this. The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns. | have attached our current delay action plan that has recently been reviewed. At a local level, the Trust has a number of ongoing actions in Norfolk aimed at addressing the handover delays. Daily system calls take place between EEAST, and other stakeholders, chaired by the ICB (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interim measures that need to be put in place. The ‘Category 1 drop and go’ and ‘Category 2 rapid release’ projects are also in place although these are not always available at the acute due to capacity. To highlight the nature of the handover delays, last month we lost 6295 hours of ambulance time outside hospitals in Norfolk waiting to handover, after the 15-minute handover period (i.e., not including that time). This does not account for the hours spent ‘cohorting’ patients, nor the lost manager time supporting this. As can be seen the effect on our C2 response time is hugely significant and correlates directly with delayed handovers. Escalations continue to take place regularly at executive level to try and ease this situation, but the trend nevertheless is still currently worsening. Impact of Norfolk Hospital delays 7000 55:12 6000 40:48 5000 26:24 4000 12:00 57:36 3000 43:12 2000 28:48 1000 14:24 Axis Title The initiative mentioned earlier relate to the ‘Category 1 drop and go’ process which means that if a Category 1 call is received and there is a crew waiting with a patient at hospital, the crew can drop their patient off immediately to attend to the Catego patient. Equally, the ‘Category 2 rapid release’ means that if a Category 2 patient has een assessed over the phone by a Clinical Co-ordinator and revalidated as a valid Category 2 call, the rapid release programme allows a crew to handover a patient at the hospital within 10 minutes to allow that crew to then attend to the Category 2 patient. The aim of these schemes is to help improve the response time to patients who are suffering with chest pain or potentially having a stroke. Furthermore, the Association of Ambulance Chief Executives (AACE) released a briefing for HM Coroners in relation to hospital handover delays and delayed ambulance responses to 999 calls and this was shared with your office on 30 August 2022. | have also attached a copy for your information. | am sorry for the delay that Barbara Hollis and her family experienced and | would be grateful if you could pass a copy of this letter onto Barbara’s family. Yours sincerel Chief Executive
Private and Confidential HM Coroners Court County Hall Norwich NRl 2DH 4'" November 2022 Dear Madam S2 Spire Norwich Hospital Spire Norwich Hospital Old Wat~on Road Colney Norw;ch NR4 7TD Following the three inq uests held earlier this ye~r in relation to the deaths ofl Barbara I am w riting to update you on actions taken in response to t he re commendations you made: • Ensure all patients admit ted to Spire No rwi ch Hospital are aware that the hospital does not have an on-site critical ca re unit In liaison with East of England Ambulance Service, agree a process t o support timely • ambulance transfers and early notification of when an ambulance is required In order to ensure.all patients are aware that Spire Norwich Hospit al does not have a critical care unit, we have added the following word ing to patient admission letters: In the unlikely event of an unforeseen emergency requiring specialist care or facilit ies not available at Spire Norwich Hospital, it may be necessary to transfer you to the Norfolk and Norwich University Hospital. If this is necessary, it will be as an NHS patient, as many services are simply not provided privately in these circumstances, and rapid emergency NHS treatment would be in your best interest. I met with (EEAST) on the 1311' October 2022 to discuss options to improve ambulance response times fo r inter- , Patient Safety Officer (EEAST) and , Control Room Lead provider transfe rs. We discussed the pressure facing the ambulance service at this time in gre at detail and took the time to explain that it w ould not be possible to provide any assurance regarding ambulance response times or to agree an early notification or booking service as you had suggested, due to t he req uirement to manage demand through the existing triage and prioritisation syst em. However, w e did acknowledge that the ability to have a clinician t o clinician d iscussion, where Spi re senior nursing or medical staff can spea k to a clinica l lead within EEAST w ould enable det ailed information to be provided regarding the rational e for transf er and patient condition. This would provide the ambulance service wi th more cli nical information to assist with prioritisation of resources along w ith providing Spire statt more information in relatio n to wait ing times, thus assisting w ith patien t care management plans whilst awaiting transfer. Therefore, we have agreed the following; • On occasions where a delayed response to an IFT request is advised the caller may wish t o sp eak to the EOC Clinical Co-ordinator direct ly, or request a clinical review, for consideration of a Priority Response, Rapid Release or Drop and Go to facilitate a more prompt response. Details ot the reques t, including caller contact name and number, and a brief summary of any information pertinent to the request (such as treatment window or risk of deterioration) shoulci he recorded in CAD notes anrl escalated t o the Clinical Co-ordinator throu~h no rmal esca lation channels. • The EOC Clinical Co-ordinator is to review any such request as per normal process and decision making taking into account community risk and demand. Any decision must be communicated to the clinician making the IFT request and re levant dispatch team as required. We continue to consider other options to support t imely transfer of patients, including liaison with private ambulance providers. The cha llenges with ambula nce transfer delays have been reported to Spire Healthca re' s Executive committee and we are being supported to seek solutions to t his challenge at a national level. Kind regards Director of Clinical Services
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