Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0284, written 14 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2022 |
|---|---|
| Reference | 2022-0284 |
| Deceased | Irene Davies |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 8th March 2022 I commenced an investigation into the death of Irene Annie Davies. The investigation concluded on the 19th August 2022 and the conclusion was one of Narrative: Died from Natural Causes contributed to by the complications of an accidental fall and an infected nephrostomy tube. The medical cause of death was 1a) Congestive Cardiac Failure on the background of Urinary Tract Infections; II) Bleeding from a fall, Infected Nephrostomy, Atrial Fibrillation, Extra- Articular Fracture 4 CIRCUMSTANCES OF THE DEATH Irene Annie Davies had multiple underlying health issues including congestive cardiac failure. She had a nephrostomy as a consequence of renal stones. An operation for renal stones had been delayed due to a combination of factors including delays and backlogs in elective surgery. She had repeated urinary tract infections as a consequence of the nephrostomy. On 1st March 2022 she had an accidental fall at her home address She sustained significant lacerations and bled profusely. An ambulance was called, she was identified as requiring a category 2 response. Due to demand it was in excess of an hour before an ambulance attended at her home address. She was taken to Stepping Hill Hospital. She was found to have a fracture of the vertebrae and to have symptoms of a urinary tract infection. She was treated with antibiotics. On 2nd March 2022 at Stepping Hill Hospital she was found unresponsive. 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 Mrs Davies was identified as requiring surgery and the discomfort she was in due to the renal stones and from the nephrostomy. Pre-COVID the wait time for surgery was 18 weeks. It had risen to 2 years at the time she required the surgery due to challenges in providing elective surgery during COVID. The Inquest heard that the Trust had been working to clear the backlog and reduce the waiting time but that it still stood at 12 months; 2. The evidence given to the Inquest was that after falling Mrs Davies needed an ambulance urgently - a Category 2 response. The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time. The Inquest heard evidence that there was an ongoing issue of ambulance availability. 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 9th November 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Family, who may find it useful or of interest. on behalf of the 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 14.09.2022 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.
•Department of Health & Social Care Alison Mutch Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Will Quince MP Minister of State for Health 39 Victoria Street London SW1H0EU 13th January 2023 Thank you for your letter of 14 September 2022 about the death of Ms Irene Annie Davies. I am replying as Minister with responsibility for Health and Secondary Care. Firstly, I would like to say how sactdened I was to read of the circumstances of Ms Davies' death and I offer my sincere condolences to her 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). Regarding your concern about elective surgery waiting times, the pandemic has put enormous pressure on the NHS with elective waiting lists growing to over 6.8 million patients, but we remain committed to ensuring people get the right care at the right time. During the peak of the pandemic in the first wave, we focussed on caring for COVID-19 patients while also prioritising urgent treatments like surgery for cancer and other lifesaving operations. To prevent the NHS from becoming overwhelmed and ensure it could deliver the essential services needed to deal with COVID-19, NHS England issued guidance to postpone all non-urgent elective ·activity for three months. However, this step resulted in a large number of cancelled and postponed appointments and procedures, including surgical procedures. I appreciate this must have had a significant impact on a huge number of people across the country, many of whom were experiencing pain or anxiety whilst waiting. This translated to record high waiting lists and over 20,900 patients waiting for up to two years or more for treatment (104+ weeks) at the pea,k in January 2022. Such numbers were unheard of prior to the pandemic. While every effort was taken to deliver as much NHS activity as possible, there have undoubtedly been unfortunate and tragic consequences as a result of the pandemic. The NHS is working tirelessly to reduce the backlog <?f planned treatment. In February 2022, the NHS published its Delivery Plan for Tackling the COVID-19 Backlog of Elective Care.1 The government plans to spend more than £8 billion from 2022-23 to 2024-25, in addition to the £2 billion Elective Recovery Fund and £700 million Targeted Investment Fund already made available to systems last financial year, to help drive up and protect elective activity. The Delivery Plan also set clear ambitions to eliminate long waits for planned NHS treatment. The overall vision is to eradicate waits of longer than a year for elective care by March 2025. The first stage of meeting this ambition was to eliminate long waits of two years or more for elective procedures by July 2022, excluding patients waiting by choice or due to complex specialties. Thanks to the incredible hard work of NHS staff, we virtually eliminated two-year waits for treatment by July 2022. The number of two-year waiters was reduced from more than 22,500 at the start of the year to just 2,777. Since its peak in January 2022, we've seen the number of people waiting two years for treatment with acute NHS providers fall by nearly 90% to the start of July 2022. We are making progress on tackling the backlog and continue to work towards the next long waits ambition, that no one is waiting over 18 months by April 2023, nor over 65 weeks by March 2024. Patients will have a choice about their care at the point of referral, and this will be enhanced for long-waiting patients through a national hub model. This will offer long- waiting patients further choice about their care, at an earlier point in their journey over time as the NHS brings down the longest waits from over two years to under one year. We are also providing better information and support to patients while they are waiting, so that people are better informed about their care and are more prepared for their treatment or procedure. Furthermore, we have invested £1.5 billion in new surgical hubs and other investments to help elective surgical services recover. Elective surgical hubs are units that conduct planned procedures only and are often referred to as 'cold sites'. They might exist within a hospital as a distinct unit or ringfenced theatre; or they might have been established on a separate site. They provide COVID-19-secure environments, with dedicated facilities bringing skills and resources together under one roof, with staff caring only for planned patients (who can be tested for COVID in advance) to minimise the risk of infection and reduce cancellations, enabling more patients to be seen. There are currently 92 elective surgical hubs that are operational across England. In August 2022, we confirmed that over 50 new hubs wiil open to deliver almost 2 million extra routine operations to reduce waiting lists over the next 3 years, meaning that over 140 surgical hubs will be open in England by 2024/25. Turning to your concern about ambulance delays, 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. 1 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan- for-tackling-the-covid-19-backlog-of-elective-care. pdf As announced in the Autumn Statement, the government is investing an additional £3.3 billion in each of 2023-24 and 2024-25 to 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, including plans to improve Category 2 ambulance response times to 30 minutes. 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, and freeing up ambulances to respond to emergencies. There are a range of measures in place to improve ambulance performance. 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 of capital funding to upgrade the ambulance fleet in each year to 2024/25, reducing the age profile of the fleet, increasing productivity, and reducing emissions (including 30 zero emission ambulances). Addressing 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. 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. The NHS is also 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. 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. The NHS will also expand 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. On ambulance workforce, we have made significant investment with the number of NHS ambulance staff and support staff increased by over 40% since September . 2010. Health Education England also 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 dem·ands on the service. 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. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, WILL QUINCE MP MINISTER OF STATE FOR HEALTH 6
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