Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0065, written 20 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 | 20 Feb 2023 |
|---|---|
| Reference | 2023-0065 |
| Deceased | David Strachan |
| Coroner | Kate Sutherland |
| Coroner area | North Wales (East and Central) |
| Category | Wales prevention of future deaths reports (2019 onwards) · Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Sutherland Assistant Coroner for North Wales (East and Central) REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Welsh Ambulance NHS Trust Betsi Cadwaladr University Local Health Board 1 CORONER I am Kate Sutherland, Assistant Coroner, for North Wales (East & Central). 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 24 March 2022, an investigation was commenced into the death of David Colin Strachan . T he investigation concluded at the end of an Inquest on 14 February 2023. The conclusion of the inquest was a narrative conclusion. The cause of death was recorded as:- 1a. Acute myocardial infarction 1 b. Coronary artery atheroma 4 CIRCUMSTANCES OF THE DEATH David Strachan was aged 76 years when he died on 16th March 2022 at his home ad dress in Uangollen, Denbighshire. At 23.20 hours on 15 March 2022, he ex perienced a sudden onset of chest pain, vomiting and became clammy with sh ortness of breath. A number of 999 calls were made to the Welsh Ambulance Se rvice but it was not until 9.1 0am, some 9 hours and 52 hours from the initial call that an ambulance and paramedics arrived. An ECG by paramedics indicated that Mr Str achan had suffered an ST elevation myocardial infarction. He was conveyed directly to the North Wales Cardiac Centre at Ysbyty Gian Clwyd and following investigations he was transferred to the Coronary Care Unit. On arrival his breathing weakened and he CO died at 12.27pm on 16 March 2022 in hosoital. RONER'S CONCERNS 5 Du ring the course of the inquest the evidence revealed matters giving rise to concern. In circ my opinion there is a risk that future deaths will occur unless action is taken. In the umstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - [he causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were lsignificant handover delays across all BCUHB sites. The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in brder to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed !ambulance attendances caused by these multifactorial issues. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 17 April 2023. Only, 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 Mr Strachan's family and the Chief Coroner. 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 20 February 2023 SIGNED: Kate Sutherland, Assistant Coroner for North Wales (East & Central)
2 responses 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.
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Dyddiad / Date: 17 April 2023 Kate Sutherland Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Dear Ms Sutherland, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS David Strachan I write in response to the Regulation 28 Report to Prevent Future Deaths dated 20 February 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of David Strachan. I would like to begin by offering my deepest condolences to the family and friends of Mr Strachan. In the Notice, you highlighted concerns regarding ambulance handover delays and the consequent availability of ambulances within the community. I note that the Welsh Ambulance Service Trust, as joint parties to the Notice, will also respond to you. I wish to fully acknowledge that you and the Senior Coroner have raised the issue of ambulance handover delays previously, and I wish to fully assure you that the Health Board is committed to doing all it can to address the issues. I understand the frustration that you will have, that despite our improvement actions, the issue is not resolved. I share those frustrations and am committed to seeing improvements. The causes behind this issue are complex and long standing, exacerbated by the global COVID-19 pandemic. In many cases, the solutions sit outside of the Health Board or require joint working across the whole spectrum of health and social care. There is no quick or easy solution to these challenges and in this letter I aim to set out the position and our improvement plans. Current position By way of a short overview, we continue to see significant pressures in unscheduled care across Wales with a worsening position nationally for the Emergency Department (ED) performance across 4 hour, 12 hour and ambulance handover delays. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk There are ongoing challenges in the ability to discharge the number of Medically Fit For Discharge (MFFD) patients which continues to impact on flow across the unscheduled care system, which is also impacting on planned care services. The numbers of patients who are Medically Fit For Discharge and are delayed within a hospital bed remains consistently high across the acute and community hospitals, with 1/3 of the Health Board beds being occupied by patients awaiting discharge, which heavily impacts on flow and performance. There are social care challenges to recruit into vacant posts, and within the current social economic position there are conflicting recruitment campaigns ongoing for the same staff that is heavily influencing the ability to recruit. The number of ambulance attendances do remain static but there has been a sharp increase in the acuity of those attending EDs, with a notable increase in frailty patients who are experiencing prolonged delays at home awaiting an ambulance response due to the inability to release ambulances from sites. Infection prevention issues continue to fluctuate with bed closures across the Health Board with areas closed due to the risk of increased infection. This has not only reduced flow, but also reduced our ability to safely discharge patients who are positive for an infectious condition. We have also noted an increased primary care demand due to the acuity of patients presenting for consultation, which has resulted in an increase in referrals for hospital assessment/admission. Due to delays in ambulances attending calls which are held at sites, this has resulted in patients arriving later on in the day, leading to further delays in assessments, and then requiring admission via ED. The increase in ambulance delays also results in patients self-presenting at EDs, including those who could have been routinely assessed and discharged on scene by ambulance crews that wouldn’t have been conveyed to ED. Furthermore, patients with more serious conditions and have a higher acuity are self-presenting to EDs due to the inability for an ambulance to attend. Due to the constant demand 24/7, there is now a growing picture of delays during the out of hours periods due to capacity within the three Integrated Health Communities (IHCs) and an increase in patient moves on wards during the out of hours period. Currently the data shows more moves out from EDs during the out of hours period against the in-hours period. The implications around out of hours moves are multiple, for example, patients are subsequently not seen by speciality team due to reduced staffing out of hours and resulting in longer delays for investigations/assessments that may support the patient journey and prevent un-necessary admissions to beds. Our improvement plans Local schemes were put in place to support the recent industrial action in December and January that had a positive outcome. Following on from this, there will be a site management/Emergency Department workshop to identify what can be done as business as usual following on from our learning from the industrial action. A task and finish group is established with support from the National Collaborative Commissioning Unit (NCCU) to develop an urgent improvement programme that will report into the National Ambulance Commissioning Group along with local NHS Wales Executive meetings that will support the Six Goals Programme for urgent and emergency care (detailed below). The Unscheduled Care Programme within the Health Board is being progressed in conjunction with the Welsh Government Six Goals Programme for improving Urgent and Emergency Care. The Six Goals programme of work is being led by a recently appointed Programme Director working with a Clinical Improvement Lead and the Deputy Executive Medical Director, as the Senior Clinical Leads for the programme, supported by the Acting Associate Director for Urgent & Emergency Care. The refreshed Health Board Six Goals Programme Group has been established with terms of reference, agreed membership and meetings in place which will be chaired by myself. A reporting framework and accountability arrangements within our IHC teams and associated stakeholders are being agreed and finalised. The Six Goals programme team are focusing on immediate action plans to support a number of high impact interventions that aim to deliver improvements in both patient and staff experience as well as organisational performance. There will also be an emphasis on developing wider projects with the programme to support the medium and long-term aspirations for Urgent and Emergency Care over the coming years. This includes but is not limited to: i) Working with our IHC teams to support initiatives for Urgent and Emergency Care improvement trajectories in line with the Six Goal Programme. ii) Support Welsh Government funding opportunities for high-risk patients – work is also ongoing within each IHC to identify high risk patients to co-ordinate planning for individuals at risk. iii) Support for patients within care homes and work on admission avoidance is being tested from January 2023 onwards. Stakeholder meetings are almost complete and contracts are being prepared. iv) Broader review of urgent and emergency care within the community which is underway with an appetite for collaboration. v) Continued focus on safe alternatives to admission through Same Day Emergency Care units (SDEC) and Urgent Primary Care Centre developments, which are established but further work is underway to address space and staffing issues. vi) Continue to drive technology support for the programme. A pilot was undertaken from November 2022 to January 2023 to reintroduce the national census reporting of the former delayed transfers of care (DTOC), which was stood down in early 2020 due to the pandemic. The reporting process has been refined with delay codes amended to align with the revised pathways. This reporting process is a ministerial priority. The Health Board and the 6 local authorities are working together to ensure accurate data is inputted and validated. The process was implemented with go live from February 2023 onwards and the next phase of the reporting process going forwards will require integrated action plans to be developed to identify themes and trends to inform what gaps within services require funding and support. It is expected that these action plans will be reviewed through Health Board Unscheduled Care (Six Goals) Groups and also at the Regional Partnership Board. In line with the national 1000 beds campaign, work is continuing locally in partnership with the 6 local authorities across North Wales to progress a number of schemes identified to increase capacity. A total of 18 schemes are in place currently with trajectories that aim to deliver 221 additional beds or placements out of the required 243 target set for North Wales. Of the 18 schemes, 7 are amber where they are not currently on trajectory and 11 are green. Key challenges to delivery of the schemes is around recruitment of additional staff. Further pipeline schemes are also being worked in each county for additional capacity to achieve the 243 target and learning is being shared between our IHCs and the counties. Current highlights from the schemes include; Recruitment of micro-providers in Denbighshire to support increased provision of domiciliary care in the county. Significant overseas recruitment within a care agency in Wrexham which to date has reduced the number of hours of packages of care awaiting in the county. Peripatetic service in Conwy set up to respond to urgent demand for provision of short to medium term personal care and support to individuals within their own homes, working closely with the reablement team to pick up new packages of care in the county and support hospital discharges. The Tuag Adref (Homeward Bound) and District Nursing service in the West IHC is supporting with the provision of a number of packages of care where the local authorities have confirmed they are unable to provide within the required timeframe. A recruitment process has successfully appointed additional Health Care Support workers to Tuag Adref and the service is also in the process of becoming registered as domiciliary care provider with Care Inspectorate Wales (CIW). Work is ongoing to commission targeted care home placements to provide specialist step down to recover rehabilitation beds and step-up, short-term rehabilitation support through block purchasing arrangements. Following an exercise to invite Expressions of Interest from over 300 residential and nursing care homes, responses were received from only 7 homes across North Wales totalling 35 placements. An evaluation process was undertaken of the applications received which resulted in 5 of the 7 homes being awarded contracts for a total of 21 additional placements, some of which were not suitable due to being under review by Care Inspectorate Wales or subject to escalating concerns. A further review will be undertaken once these circumstances change. It is also anticipated that further placements will be available from additional submissions from care homes, which did not submit within the deadline. Alongside the Six Goals work stream and as part of the operational focus on the Unscheduled and Emergency Care framework: The ICAP (Integrated Commissioning Action Plan) is a joint piece of work with WAST/NCCU and the Health Board to support actions associated with improving ambulance handovers. Joint reviews between WAST and the Health Board of any patient safety incidents identified the improvement programmes. The process within the Health Board has been identified as the gold standard model and being rolled out across Wales. joint working alongside from handover delays to support A review is underway of the hospital full protocols and setting of a benchmark of acceptance. Developing a 7 day discharge lounge in line with the 7 day NHS services commitment, and reviewing capacity of discharge lounges to reduce restriction. We closely monitor all the performance metrics related to unscheduled care, including ambulance handover delays, through our Integrated Quality and Performance Report which is received at the Health Board and its various Committees. The Health Board also receives regular updates on our improvement work in the Six Goals Programme. Conclusion This letter sets out for you the significant challenges faced in reducing ambulance handover delays, and explains how this is a complex, multi factorial issue. But I hope this letter also offers you assurance that the Health Board is undertaking significant improvement activity and where needed working with partners and stakeholders. As I wrote earlier, the solutions are complex and there is no easy fix. However, the Health Board remains committed to doing all it can to reduce handover delays and improve the safety and experience of our services for the patients we serve. We would be happy to meet and discuss the challenges and our plans in more details, or provide further information should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mr Strachan for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc Deputy Director of Quality
Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office 17th April 2023 PRIVATE & CONFIDENTIAL Ms Kate Sutherland Assistant Coroner for North wales (East and Central) Dear Ms. Sutherland Re: Mr. David Colin Strachan I write in response to the Prevention of Future Deaths Report issued to this Trust on the 20 th February 2023, following the inquest in relation to Mr. David Colin Strachan. The matters of concern that you have asked the Trust to consider are: “The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites. The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.” I have already shared with you, in our response in relation to Mr. Raymond Gillespie, the actions the Trust has already taken as a response to the concerns regarding patient safety at times Mae’r Y mddiriedolaeth y n croesawu gohebiaeth y n y Gy mraeg neu’r Saesneg, ac na f y dd gohebu y n Gy mraeg y n arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.nhs.wales Anfonwch unrhyw ohebiaeth i'r cyfeiriad canlynol:- Please forward any correspondence to the following address:- Beacon House William Brown Close Llantarnam Cwmbran NP44 3AB Ffôn/Tel 01633 626262 when ambulances are unavailable. Additionally, we have shared with you the measures that are currently in place such as the Clinical Safety Plan and the Regional Escalation Action Plan. I will not repeat those within this response to you, however, the Clinical Safety Plan was revisited in December 2022 and I attach at appendix 1, a copy of the latest plan. The Trust has previously provided evidence to coroners pan-Wales regarding the actions that have been taken in order to reduce the lost hours and improve our response times for patients waiting in the community. In my response to you regarding Mrs. Glynis Roberts, I shared a copy of the Reducing Patient Harm Action Plan that had been tabled in our Trust Board meeting. This Action Plan continues to be monitored, updated and tabled at Trust Board meetings. I attach for your reference copies of the plan, and associated reports, that was presented to the Trust Board on the 26th January 2023 and 30th March 2023. Presented alongside the plan are reports regarding the actions being taken to mitigate in real time, avoidable patient harm, in the context of extreme and sustained pressure across urgent and emergency care. Please find these documents at appendix 2 – 4 attached. While writing, I would like to extend my sincere condolences to Mr. Strachan’s family on their sad loss. I would again like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continued improvement to support the prevention of harm and future deaths. Yours sincerely Chief Executive Enc: App1 – Clinical Safety Plan App 2 – Trust Board January 2023 Actions to Mitigate Avoidable Patient Harm App 3 - Trust Board Progress of Actions to Mitigate Avoidable Patient Harm (March 2023) App 4 - Improvement Plan March 2023 - Patient Harm Mitigation Action Plan 2
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