Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0042, written 4 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2023 |
|---|---|
| Reference | 2023-0042 |
| Deceased | Benjamin Stanley |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation 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: The 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 24th May 2022 I commenced an investigation into the death of Benjamin Paul Stanley. The investigation concluded on the 15th November 2022 and the conclusion was one of Narrative: Died as a consequence of malnutrition caused by chronic pancreatitis contributed by liver cirrhosis and the complications of necessary antibiotic therapy. The medical cause of death was 1a) Multi organ failure; 1b) Malnutrition; 1c) Chronic Pancreatitis; II) Clostridium Difficile Infection, Liver Cirrhosis, Sepsis 4 CIRCUMSTANCES OF THE DEATH Benjamin Paul Stanley developed chronic pancreatitis. He became severely malnourished as a direct consequence of his chronic pancreatitis. He was admitted to Stepping Hill Hospital on 11th May 2022 and was very unwell. He had become severely malnourished. It was identified that he had liver cirrhosis in addition to the chronic pancreatitis. He was treated but continued to deteriorate. He developed sepsis and was treated further. He was found to have developed clostridium difficile probably as a consequence of antibiotic therapy. He died at Stepping Hill Hospital on 19th May 2022. 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. 1 The MATTERS OF CONCERN are as follows. – The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department. The Inquest heard that the position had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment. The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester. The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital. In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed. 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 1st April 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 namely Mr Stanley on behalf of the Family and Stockport NHS Foundation Trust via Hempsons Solicitors, 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. Alison Mutch OBE HM Senior Coroner 04.02.2023 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.
From Helen Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU 25 April 2024 Ms Alison Mutch OBE HM Coroner Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter of 4 February 2023 to the Secretary of State for Health and Social Care about the death of Benjamin Stanley. I am replying as Minister responsible 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 Mr Stanley’s death and I offer my sincere condolences to their family and loved ones. The report raises concerns about Accident and Emergency (A&E) waiting times and a lack of bed capacity at Stepping Hill Hospital, Stockport NHS Foundation Trust. I am grateful to you for bringing these matters to my attention. In preparing this response, my officials have made enquiries with the Care Quality Commission (CQC). The CQC notes that there are improvements at the trust including work to increase the footprint of their emergency department, the provision of an additional ward for medically optimised patients to help free up beds, and work with local care home providers to focus on ways to increase community capacity to further enable prompt patient discharges. As the Minister responsible for urgent and emergency case services, I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our delivery plan for recovering urgent and emergency care services which aims to deliver sustained improvements in emergency waiting times. The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter. We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E. NHS England also launched its universal support offer, available to all systems, including Stockport NHS Foundation Trust which supported systems to implement high impact initiatives and improve emergency care performance ahead of winter this year. We have seen improvement in A&E waiting times this year following the delivery plan’s publication. National A&E 4-hour performance improved by 3.3ppt to 74.2% in March 2024 from 70.9% in February 2024, and up from 71.5% in March 2023. However, we recognise there is more to do, and reducing waiting times is a priority for this Government. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
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