Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0044, 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 | 2023-0044 |
| Deceased | Patricia Green |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Emergency services related deaths (2019 onwards) · 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: 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 4th July 2022 I commenced an investigation into the death of Patricia Grace Eileen Green. The investigation concluded on the 11th January 2023 and the conclusion was one of Narrative: Died from Covid 19 pneumonia contributed to by a fall with a prolonged long lie following the fall. The medical cause of death was 1a) COVID-19 Pneumonia on a background of a fall with a long lie; II) Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease, Frailty, Acute Renal Failure. 4 CIRCUMSTANCES OF THE DEATH Patricia Grace Eileen Green had an accidental fall at her home address. She fell in such a way that she was left in a prone position on the floor. An ambulance was called. There was a 9 hour wait for the ambulance due to the demands on the ambulance service. She remained prone on the floor during the wait. She deteriorated particularly in relation to her breathing whilst waiting for an ambulance .She was unable to access toilet facilities whilst waiting for an ambulance On arrival at Tameside General Hospital, she was seen by a doctor after a 3 hour wait. She was found to have Covid 19 pneumonia. She continued to deteriorate and died at Tameside General Hospital on 30th June 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. – 1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients; 2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest; 3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients. 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 Mrs Green’s son on behalf of the Family and the North West Ambulance Service, 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. 2 9 Alison Mutch OBE HM Senior Coroner 04.02.2023 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 Helen Whately MP 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 17 May 2024 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 Patricia Grace Eileen Green. 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 Green’s death and I offer my sincere condolences to her family and loved ones. I am grateful to you for bringing these matters to my attention. Your report raises concerns over the high demand and shortage of ambulances across Greater Manchester due to long delays at emergency departments. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE recognise the significant pressure on ambulance services since the Covid-19 pandemic as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. Further, my officials advise me that Greater Manchester Integrated Care Board wrote to you in August to provide information on the improvements being made locally supporting improved ambulance response times and reductions in handover delays. 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 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- 1 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 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. At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%. NWAS average Category 2 response times were over 13 minutes faster in 2023-24 compared to the previous year, a 32% reduction. However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours, HELEN WHATELY
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