Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0112, written 31 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2023 |
|---|---|
| Reference | 2023-0112 |
| Deceased | Veronica Jenkins |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | South East Coast Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Veronica Jenkins A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Acting Chief Executive South East Coast Ambulance Service 4 Gatwick Road Crawley Sussex RH10 9BG Rt. Hon. Steve Barclay Secretary of State for Health and Social Care 39 Victoria Street London SW1H OEU 2 CORONER Miss Anna Crawford, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 1 4 INQUEST An inquest into the death of Mrs Jenkins was opened on 7 June 2022. The inquest was resumed and concluded on 30 January 2023. The medical cause of Mrs Jenkins’ death was: 1a. Small Bowel Ischaemia 1b. Intra-Abdominal Adhesions due to Previous Surgery The inquest concluded with a short narrative conclusion of ‘Recognised Complication of Surgery’. 5 CIRCUMSTANCES OF THE DEATH Mrs Jenkins was a 72 year old woman with a diagnosis of bowel cancer for which she underwent a surgical resection in 2016. Thereafter, she had a further procedure to reverse her ileostomy in 2017. In 2022 the cancer spread to her lungs and it was planned for her to commence chemotherapy in May 2022. However, late at night on 10 May 2022 Mrs Jenkins developed sudden onset chest pain and was taken to St. Peter’s Hospital, Chertsey, by ambulance. En route to the hospital at 00:39 on 11 May 2022 she suffered a cardiac arrest and was successfully resuscitated at 00:56. She suffered a further cardiac arrest at 01:18 shortly after the ambulance arrived at the hospital and efforts to resuscitate her were not successful and she died at the hospital on 11 May 2022. The cardiac arrest had resulted from Small Bowel Ischaemia which was due to Intra-Abdominal Adhesions, which is a recognized complication of the previous abdominal surgery she had undergone. The court found that there was a delay in the ambulance response for Mrs Jenkins on 10 May 2022 but that the delay did not materially contribute to her death. With respect to the delay, the court heard that the 999 call for an ambulance was made at 23:11 on 10 May 2022 and was correctly triaged at 23:14 as a Category 2 call. Category 2 calls have a mean response time of 18 minutes according to the national framework governing ambulance response times. However, an ambulance did not arrive to Mrs Jenkins’ address until 23:47, which is a response time of 33 minutes, and therefore a delay of 15 minutes. 2 The court heard evidence from , Operations Unit Manager at South East Coast Ambulance Service (SECAMBS), that on 10 May 2022 the service was experiencing exceptional demand and the response times for all categories of 999 calls were experiencing significant delays with an increased potential for patient safety and care to be compromised. gave evidence that the delays were due to a deficit in the amount of operational hours that SECAMBS was able to provide on 10 May 2022. The overall required operational hours across the region were 9,652 and on 10 May 2022 only 9,064 were provided, which is a deficit of - 6.1%. With respect to the Chertsey area particularly, the required operational hours were 822.00 and only 751.75 were provided, which is a deficit of -8.5%. gave evidence that the deficit was due to two factors – 1. A lack of availability of staff due to a combination of sickness, covid related absence and annual leave; and 2. Handover delays at hospitals leading to a loss of 191.04 operational hours across the region on 10 May 2022. Having heard the evidence, the court was not reassured that these factors would not reoccur in the future, as such giving rise to the risk of future deaths. 3 6 CORONER’S CONCERNS The MATTER OF CONCERN is: There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety. This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region. The first issue is addressed to the Chief Executive of SECAMBS and the second issue is addressed to the Secretary of State for Health and Social Care. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 4 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mrs Jenkins’ family 10 Signed: ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 31st day of March 2023 5
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.
From Minister Whately Minister of State for Health and Social Care 39 Victoria Street London SW1H 0EU 2 April 2024 Annex A Anna Crawford Coroners' Court Station Approach Woking Surrey GU22 7AP Dear Ms Crawford, Thank you for your letter of 31 March 2023 to the Secretary of State for Health and Social Care about the death of Veronica Jenkins. 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 Ms Jenkins’ 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 about ambulance response times by South East Coast Ambulance Trust (SECAmb). In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). I note they have responded separately to you and provided a response which addresses how they are increasing availability of staff and are working with partners to address handover delays. As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the ambulance service has been facing, including SECAmb. That is why we published our ambitious Delivery plan for recovering urgent and emergency care services. This aims to deliver sustained improvements in waiting times, reducing Category 2 response times to 30 minutes on average this year. Your report also highlights pressures on SECAmb’s operational capacity at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services are receiving £200 million of additional funding this year to expand capacity and improve response times 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. Regarding handover delays, a key part of the plan has been to increase hospital capacity to improve patient flow. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £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. These measures will improve patient flow through hospitals, reducing delays in ambulances handing over patients so they 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. In addition, the NHS Long Term Workforce Plan published in June 2023 sets out how the NHS will address existing and future workforce challenges by recruiting and retaining thousands more staff over a 15-year period and working in new ways to improve staff experience and patient care. This will help ensure we have the ambulance workforce to meet the future demands on the service, building on the 40,000 more ambulance staff that have already joined the service since 2010. At a national level, we have seen significant improvements in performance this year compared to last year. In winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a 24% reduction. For SECAmb, in 2023-24 winter, their average Category 2 response times was over 5 minutes faster compared to the same time period last year, a 16% reduction. Thank you once again for bringing these important issues to my attention. Yours, HELEN WHATELY
Ms Anna Crawford HM Assistant Coroner for Surrey By email only 18th May 2023 Dear Madam Coroner Mrs Veronica Jenkins deceased I write in response to your Regulation 28 Prevention of Future Deaths report dated 31st March 2023. I was very much saddened to read of Mrs Jenkins’ death and I would like to express my personal condolences to her family. Senior members of the operational management team have met to discuss the concerns you raised and how best to address them. We have also liaised with commissioners to ensure that all parts of your report are answered by the most appropriate organisation. Addressing your concern in your report: A lack of available staff Our service at the time was funded for 2413 whole time equivalents (WTE) and SECAmb frontline operations is now funded for 2555 whole time equivalents (WTE). We have a current vacancy rate of 13.2% as at 31 March 2023. This means that we have 2239.7 whole time equivalent people out of a possible 2555 posts. To remain on the trajectory to reach 2555 whole time equivalent people, with our current training and recruitment capacity, SECAmb had planned for 2370.1 WTE by 31 March 2023. However, 2239.7 WTE were in post on that date, a difference of 5.7% against plan across the Trust. More newly qualified paramedics are seeking employment in GP surgeries and other primary care settings which leads to less new staff applying to work in the ambulance service. Within the Chertsey Operating Unit (OU), SECAmb had planned for 202.8 whole time equivalent staff to manage the demand in that area. However, as at 31 March 2023, we had 179.7 WTE in post, a difference of 12.1%. Chertsey is our second most understaffed OU. This is due to close proximity to London (and London Ambulance Service) with very good transport links. We commission and utilise private ambulance provision across the region to fill the gap caused by vacancies and we also rely on staff working on overtime. The impact of Covid and Long Term Covid sickness also had an impact on the number of staff available to work each shift. Whilst the day that this incident occurred was under resourced due to less staff available to work than was needed, it is important to put this into context of what is happening at a national level. Below are “league tables” showing SECAmb’s performance for category 2 and 3 responses against the other 10 English ambulance trusts. These figures demonstrate that response delays are a national rather than regional issue. We responded to Mrs Jenkins in as timely a manner as we were able and provided the appropriate level of treatment, giving her the best possible survival chance. We believe that within the envelope of funding allocated to SECAmb, the level of response to patients we were delivering was the best that could be achieved given the circumstances of the pandemic. Since May 2022 we have continued to recruit frontline clinicians and increase our workforce and work with our control room colleagues to implement call validation to ensure that where an appropriate and safe disposition can be achieved without dispatching an ambulance being required, it is done. This process increases availability of ambulances to respond to those who actually need a face-to-face assessment or urgent conveyance to a hospital. From April 2023 we have introduced a revision of our operational rotas with the aim of increasing the number of available staff at times of greatest patient demand (e.g. early mornings). We continue to work with commissioners and acute partners to improve hospital handover times and to ensure that the best response time possible within our funding is provided to all the patients we serve. Yours faithfully Chief Executive Officer South East Coast Ambulance Service NHS Foundation Trust
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