Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0265, 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 | 2022-0265 |
| Deceased | Christina Ruse |
| Coroner | Jacqueline 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 FUTURE 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 17 December 2021, I commenced an investigation into the death of Christina Avis RUSE aged 79. The investigation concluded at the end of the inquest on 22 August 2022. The medical cause of death was: 1a Multi-organ Dysfunction 1b) Hypovolaemic Shock 1c) Total Hip Replacement (Left) 14/12/21 1d) 2 Atrial Fibrillation, Ischaemic Heart Disease, Hypertension, Stroke, Myelofibrosis, Ex-Smoker, Chronic Kidney Disease. The conclusion of the inquest was: Misadventure. 4 CIRCUMSTANCES OF THE DEATH Mrs Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer Mrs Ruse to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital. Her condition continued to deteriorate and Mrs Ruse died on 15 December 2021. 1 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: 1.EEAST were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes. 2. There were no emergency ambulances available to assign to this call due to high call demand. 3. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. 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. 8 COPIES and PUBLICATION 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 Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS ENGLAND & NHS IMPROVEMENT who may find it useful or of interest. 2 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: 26/08/2022 Jacqueline LAKE Senior Coroner for Norfolk 3
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 Whiting Way Melbourn 20 October 2022 Cambridgeshire SG8 6NA Dear Ms Lake Inquest into the death of Christina Avis Ruse | am writing further to the inquest into the death of Christina Ruse, which took place on 22 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. Ata 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 2 4000 12:00 = oa 57:36 7 43:12 2000 28:48 1000 14:24 0 00:00 eesygcegateseatsygecpelceoeaetsgsagat thea tsyeegerteseatsyge Sages BeaSg22 2 geste Sogt= 2 gesressee= 2" gPeresSee= 2 ge <Ugguss= = <B8gyss= =—§ <BgeeSS= = <EG EE RS <2 gee“ esa gsa* Boss & mmm A-H>15 mins, hourslost ———Cl_ ——C2 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. lam sorry for the delay that Christina Ruse and her family experienced and | would be grateful if you could pass a copy of this letter onto Christina's family. Yours sincerel Chief Executive Chier Executive: Tom Aben Chair! Nicota Scrivings www.eastambonhsuk #WeAreEEASTRC
Private and Confidential HM Coroners Court County Hall Norwich NR12DH 4th November 2022 Dear Madam S2 Spire Norwich Hospital Spire Norwich Hospital Old Watton Road Colney Norw ict1 NR4 7TD Following the three inquest s held earlier this year in relation to the deaths of Christina Ruse, I am writing to update you on actions ta ken in response to t he recommendations you made: • Ensure all patients admitted to Spire Norwich Hospita l are aware that the hospital does not have an on-site critical care unit In liaison with East of England Ambulance Service, agree a process to support timely • ambulance transfers and early notification of when an ambulance is requ ired In order to ensure all patients are aware that Spire Norwich Hospital does not have a critical care unit, we have added the following wording to patient admission letters: In the unlikely event of an unforeseen emergency requiring special ist care or facil ities 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. Patient Safety Officer (EEAST) and I met with (EEAST) on the 13th October 2022 to discuss options to im prove ambulance response t imes for inter- provider transfers. We discussed the pressure facing the ambulance service at t his t ime in great detail and assu rance regarding ambulance re sponse times or t o agree an early notification or booking service as you had suggested, due to the requirement to man;ip.e demand through thP. existing triage and took the time to explain that it would not be possible to provide any , Control Room Lea d prioritisa tion system. However, we did acknowledge th at the ability to have a clinician to clinician discussion, where Spire senior nursing or medical staff can speak to a clinical lead within EEAST would enable deta iled information to be provided regarding the ra tionale for transfer and patient condit ion. Th is would provide the ambulance service with rnore cl inical inform.ition to assist with prioritisation of resources along w ith providing Spire staff more information in relation to waiting tim es, thus assisting wi th patient care management plans whilst awaiting transfer. Therefore, we have agreed the fol lowing; • On occasions where a delayed respo nse to an IFT request is advised the caller may w ish to speak to the EOC Clinical Co-ordin ator directly, or request a clinical review, for consideration of a Priority Response, Rapid Release or Drop and Go to facilit ate a more prompt response. Details of the request, including caller contact narne and number, and a brief surnrnary of any information pertinent to the request (such as treatment window or risk of det erioration) should he r@r.orded in CAD not@s ;ino escalated to the Clinical Co-ordinator throu8h norm;il escalation channPls. • The EOC Clinicdl Co-ordinator is to review any such request as per norrna l process and decision making taking into account community risk and demand. Any decision must be communicated to the clinician making the IFT request and relevant dispc.1tch team as required. W e continue to consider other options to support timely transfer of patients, including liaison with private ambulance providers. The challenges w ith ambulance transfer delays have been rPportPd to Spire Healthcare's Executive committee and we are being supported t o seek solutions to this challenge at a national level. Kind regards Director of Clinical Services
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