Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0017, written 18 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2023 |
|---|---|
| Reference | 2023-0017 |
| Deceased | Lyn Brind |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | East of England 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care: The Rt Hon Steve Barclay MP The Department of Health and Social Care 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 07 June 2022 I commenced an investigation into the death of Lyn Mary BRIND aged 61. The investigation concluded at the end of the inquest on 05 January 2023. The medical cause of death was: 1a) 1b) 1c) 2) Congestive Cardiac Failure Ischaemic and Hypertensive Heart Disease Coronary Artery Atherosclerosis and Morbid Obesity Diabetes Mellitus The conclusion of the inquest was: Mrs Brind died from cardiac failure. Her condition was not diagnosed nor treated in a timely fashion. 4 CIRCUMSTANCES OF THE DEATH On 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the Ambulance Navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind's condition continued to deteriorate and she died at 17.52 hours. 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: Regulation 28 – After Inquest Document Template Updated 30/07/2021 1) Evidence was heard that there was a delay in Mrs Brind being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital 2) As delays are a reoccurring problem, checks are made by paramedics and Hospital clinicians on patients while they wait in ambulances for transfer into the hospital to assist in prioritising the need for transfer. 3) In the case of Mrs Brind, physiological observations were not undertaken regularly in accordance with East of England Ambulance Service Trust (EEAST) Guidance and when they were taken, her high NEWS2 score was not escalated to the Hospital Ambulance Navigator who assesses priority for beds in the hospital. 4) Further Mrs Brind was not assessed by a Senior Doctor from the Hospital within an hour, in accordance with Hospital protocol 5) I am satisfied that steps have been taken by both EEAST and the Hospital in respect of these matters and do not make a report in respect of either of these matters 6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transfer patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. 7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. 8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. 7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community 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 March 13, 2023. 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 Queen Elizabeth Hospital East of England Ambulance Service NHS Trust (EEAST) Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 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: 18/01/2023 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Helen Whately MP
Minister of State for Care
39 Victoria Street
London
SW1H 0EU
25 April 2024
Jacqueline Lake
Senior Coroner for Norfolk
County Hall
Martineau Lane
Norwich
NR1 2DH
Dear Mrs Lake,
Thank you for your report of 8 January 2023 about the death of Lyn Mary Brind. I am replying
as Minister with responsibility for urgent and emergency care. Please accept my sincere
apologies for the significant 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 Mrs Brind’s
death. I offer my sincere condolences to her families and loved ones. I am grateful to you for
bringing these matters to my attention.
The report raises concerns about ambulance handover delays, capacity at Queen Elizabeth
Hospital and patient flow through the hospital including the discharging of medically fit patients.
Further, I note the report raises concerns regarding appropriate safety checks for patients
waiting in ambulances but that you are satisfied with the action taken in respect of these
matters by the East of England Ambulance NHS Trust and Queen Elizabeth Hospital King's
Lynn NHS Foundation Trust.
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, including to improve A&E wait times
to 78% of patients being admitted, transferred, or discharged within four hours by March 2025.
The plan also plan also commits to reducing average Category 2 ambulance response times
to 30 minutes 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 the hospital was under high demand with long handover delays at
the hospital at the time of the incident. I recognise that ambulance trusts work within a health
1
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 are also investing an additional £1 billion this year through the Discharge Fund, to support
the NHS and local authorities to ensure timely and effective discharge from hospital. This
funding follows £600 million last year and £500 million in 2022/23. The NHS and local
authorities are using this funding to help provide people with the right care in the right place
when they are discharged from hospital. We have also ensured every acute hospital has
access to a care transfer hub, bringing together professionals from the NHS and social care
to manage discharges for people with more complex needs who need extra support with a
view to promoting early planning and timely discharge. These measures are helping improve
patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly
get back on the roads.
We have seen improvement in urgent and emergency care performance this year following
the delivery plan’s publication. In February 2024 A&E performance at The Queen Elizabeth
Hospital King's Lynn NHS Foundation Trust for patients to be admitted, transferred or
discharged within 4 hours was 70.7%, an improvement of 8.3 ppt from the same month last
year. In March 2024, average handover times in the EEAST region were 30 minutes 12
seconds, an improvement of almost 6 minutes from the previous month. However, I recognise
there is still more to do to reduce response times down further and back towards pre-pandemic
levels – and this is the action we will continue to be taking as part of the government’s
commitment to improving NHS services and reducing waiting times.
Thank you once again for bringing these important issues to my attention.
Yours,
HELEN WHATELY
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