Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0350, written 4 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2022 |
|---|---|
| Reference | 2022-0350 |
| Deceased | Ellen MacFarlane |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | North West Ambulance Service NHS Trust |
| 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 18th March 2022 I commenced an investigation into the death of Ellen Lillian MacFarlane. The investigation concluded on the 7th September 2022 and the conclusion was one of Narrative: Died from complications of a neck of femur fracture from an accidental fall where surgery took place outside the recommended timescales. The medical cause of death was 1a) Bronchopneumonia; 1b) Neck of Femur Fracture (operated on); 1c) Fall; and 2) Dementia 4 CIRCUMSTANCES OF THE DEATH Ellen Lillian MacFarlane had an accidental fall at her care home. She had to wait for over 5 hours for an ambulance due to demands on the ambulance service. At Tameside General Hospital, it was identified that she had a fractured neck of femur. On 3rd February 2022 she was operated on. Post-operatively she was initially stable but with significantly reduced dietary intake. On 21st February she began to deteriorate and was given antibiotics for a suspected infection. She continued to deteriorate and died at Tameside General Hospital on 12th March 2022. 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 evidence that notwithstanding her age and frailty Ellen MacFarlane had to wait over 5 hours for an ambulance. This was due to the demands on the North West Ambulance Service on the day in question. The inquest heard that such delays were not unusual and were still occurring. The reason for the delay was a shortage of ambulance crews/vehicles due to a combination of high demand, staffing shortages and delays at ED; 2. Evidence before the inquest indicated that over a weekend Ellen MacFarlane required cardiac tests that could not be provided easily in a District General Hospital setting due to availability of services/staff at DGHs out of hours. As a consequence where an operation for a fractured neck of femur has been put on hold pending further tests there is an inbuilt additional delay over a weekend before a decision can be taken as to the optimum point at which to operate. This situation at DGHs appears to create a situation which is inconsistent with the drive to operate at the earliest possible point when a patient has been optimised to secure the best outcome as set out in the NICE Guidance. 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 30th December 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 Mrs MacFarlane’s Family and Polebank Hall Care Home, who may find it useful or of interest. 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 04.11.2022 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.
From Minister Whately Minister of State for Care 39 Victoria Street London SW1H 0EU Alison Mutch Senior Coroner for the Coroner Area of Greater Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG uk 17 May 2024 Dear Ms Mutch, Thank you for your letter of 4 November 2022 to the Secretary of State for Health and Social Care about the death of Ms Ellen MacFarlane. I am replying as Minister with responsibility for urgent and emergency services. Please accept my sincere apologies for the delay in responding to this matter. I would like to assure you that the Department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how saddened I was to read of the circumstances of Ms MacFarlane’s death and I offer my sincere condolences to her family. I am grateful for you bringing these matters to my attention. Your report raises concerns about ambulance response times by North West Ambulance Service NHS Trust (NWAS) and access to hospital services. In preparing this response, Departmental officials have made enquiries with NHS England. I have been reassured by NWAS that ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region and I am pleased to note performance by NWAS has improved since this sad case. My officials have consulted NHS England (NHSE) and the Care Quality Commission (CQC) regarding your concern over the availability of cardiac tests over the weekend. We are advised that, had there been an emergency need for scans outside of hours, that Ms MacFarlane would have been transferred to a tertiary centre. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance for patients with a fractured neck of femur requiring surgery. This includes urgent review of theatre capacity by the divisional management team to schedule surgeries as soon as possible, and root cause analysis of misses to identify reasons for delays and opportunities for learning. As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within 1 four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year. The plan is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads. Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to support future demand. At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, year to date average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were almost 15 minutes faster compared to the same period last year, a reduction of over 27%. NWAS average Category 2 response times were over 13 minutes faster compared to the same time period last year, a 32% reduction. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the NWAS region were 32 minutes 51 seconds. However, I recognise there is still more to do to reduce waiting/response times further, and the Government will continue to work with NHS England to achieve this. Thank you once again for bringing these important issues to my attention. Yours, HELEN WHATELY
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