Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0312, written 5 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2022 |
|---|---|
| Reference | 2022-0312 |
| Deceased | Charles Rothwell |
| Coroner | Claire Welch |
| Coroner area | Cheshire |
| Category | Community health care and emergency services 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: 1. The Secretary of State for Health and Social Care 2. The Chief Executive of NHS England 3. The Managing Director of the Association of Ambulance Chief Executives 1 CORONER I am Claire Welch, Area Coroner for the coroner area of Cheshire. 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 7 January 2022 I commenced an investigation into the death of Charles Stephen Rothwell, who died on 6 January 2022 aged 69. The investigation concluded at the end of an inquest on 4 October 2022. The medical cause of death was 1a Lobar pneumonia and my conclusion was natural causes. 4 CIRCUMSTANCES OF THE DEATH Charles Rothwell had a telephone consultation with his GP on 5 January 2022 and was diagnosed with a chest infection and prescribed oral antibiotics. During the afternoon of 6 January his condition significantly deteriorated. In a 999 call made by staff to the North West Ambulance Service at 16.26h on 6 January he was correctly triaged as a Category 3, which should have resulted in attendance within 120 minutes but he was advised that there was likely to be a minimum 11 hour wait. In a second 999 call at 1726h he was again graded as Category 3 but reminded of the 11 hour wait. In a third 999 call at 1905h he was now coughing up blood and struggling to breath so was re-graded to Category 2. At the final 999 call at 1930h he was no longer breathing and was re-graded as Category 1. An ambulance arrived at 1937 but paramedics were unable to resuscitate Mr Rothwell. The reason for the non-attendance was that demand for emergency paramedic response significantly outstripped supply. Although I concluded that the delayed arrival of paramedics did not cause or contribute to the death, it is my opinion that ongoing lack of resources means there is a risk that future deaths will occur unless action is taken. 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 1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same. 2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.” 3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h. 4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand. 5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care. 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 30 November 2022. I, the Area 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, representative for the NWAS. and the legal 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 5 October 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.
Association of Ambulance Chief Executives 16 December 2022 BY EMAIL Claire Welch Area Coroner for the Coroner Area of Cheshire Dear Ms Welch REGULATION 28: CHARLES STEPHEN ROTHWELL I am writing in response to the Regulation 28 report to prevent future deaths concerning the death of Charles Stephen Rothwell which you issued on 5th Oct 2022 to the Association of Ambulance Chief Executives (AACE). AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance service however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. In your letter you have raised several areas of concern: 1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same 2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.” 3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h. 4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand 5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care. Firstly, I would like to confirm that the issues you have raised here about capacity within NWAS are in fact a national issue for the ambulance sector and the response time delays that were experienced in this case are now present in every ambulance trust across the sector in England and also in the devolved nations to some extent. As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally. Hospital handover delays are the single biggest factor and in some ambulance trusts up to one third of all their operational hours are being lost to handover delays. This results in patients coming to harm whilst waiting in ambulances to access the emergency department and also harm to patients waiting in the community as these ambulances are no longer able to respond to those patients. The reason for these delays is complex but at the root of it is poor patient flow in the hospitals because they have large numbers of medically fit patients who are unable to be discharged due to a shortage of social care packages needed to ensure safe discharge. The resulting backlog means that ambulances cannot offload their patients within the stipulated 15 minutes and sadly in many areas we are seeing waits of several hours for patients to access ED. This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem. The second issue in play here is that we believe that ambulance services no longer have the required capacity nationally to routinely deliver the nationally mandated response time targets even if the current handover delay issues were eliminated. This is due to an inexorable rise in demand for our services and an increasing level of acuity in terms of the calls being received. AACE has flagged this issue nationally repeatedly over the last few years and has called for a national piece of demand and capacity modelling across the sector led by NHSE. I am pleased to say that this is now gaining traction and whilst in its early stages is being pursued by NHSE at the present time. This national modelling around capacity will compliment that carried out locally by ambulance trusts and their local commissioners. Ambulance Trusts including NWAS regularly conduct sophisticated demand and capacity reviews to help inform negotiations with local commissioners and I am aware that in NWAS discussions are ongoing in this area. I note in your letter that you have also addressed the PFD to the SoS for Health and Social Care and to the CEO of NHSE and this was absolutely appropriate as the system wide issues which lead to these delays must be tackled at a national level through a series of complex national initiatives designed to eliminate hospital handover delays and ensure that ambulance trusts have sufficient resources to manage demand going forward over the next five years and beyond. AACE will continue to lobby for the changes required and will continue to support its member trusts to work with the wider health system to find solutions which protect patients and ensure that they get the service they need and should expect. I hope this has answered your concerns. If I may be of further assistance, please do not hesitate to make contact. On behalf of AACE, I would also like to extend our sincere condolences to the family of Charles Rothwell. Yours sincerely Managing Director
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