Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0197, written 20 Jun 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 Jun 2023 |
|---|---|
| Reference | 2023-0197 |
| Deceased | Joan Corcoran |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Emergency services related deaths (2019 onwards) |
| 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 19th December 2022 I commenced an investigation into the death of Joan Mary Corcoran. The investigation concluded on the 15th May 2023 and the conclusion was one of Narrative: Died from complications of heart failure whilst being transported to hospital for treatment contributed to by the complications of an accidental fall. The medical cause of death was 1a) Myocardial Infarction 1b) Heart Failure 1c) Hypertension II) Neck of femur fracture (operated on) 4 CIRCUMSTANCES OF THE DEATH Joan Mary Corcoran had an accidental fall. She was operated on for a fracture to the neck of femur. Post-operatively she developed pneumonia. Subsequently the wound became infected, and a wound wash and debridement took place. She became increasingly frail. She was discharged home with support from the discharge to assess team. She felt unwell on 13th December 2022 and called for an ambulance with chest pains. Her initial call was dealt with as a category 5 call, and she contacted her GP. Her GP visited her and was concerned about her presentation. A further call to the ambulance service resulted in her being classified as a category 2 call. The blood tests taken indicated she was in severe heart failure and at a risk of a myocardial infarction. The ambulance arrived significantly outside the target Department of Health response times. The ambulance crew identified she needed urgent cardiac treatment and she was for transfer to hospital. Enroute to hospital she deteriorated further and died in the ambulance from complications of heart failure. 1 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. The MATTERS OF CONCERN are as follows. – The inquest heard evidence that under the Department of Health’s Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases. The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time. A response within the target time would have meant that she would not have deteriorated and died in the ambulance. She would have been in a hospital with access to treatment available in such a setting. The evidence before the inquest was that her case was not a one off and delays of this nature had been occurring throughout the day. The mean time for Category 2 response times that day was 1 hour and 22 minutes and the 90th percentile was just over 3 hours. At 17.58 that day there were 142 emergencies waiting in Greater Manchester alone and 430 across the North West. The average response time at that point for Category 2 patients was 2 hours and 33 minutes. The inquest heard that the cause of these significant delays in patients receiving care in a timely manner was multifactorial and included the demand for ambulances across Greater Manchester and the North West and the long ambulance delays at A and E departments due to the demand on A and E services. 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 15th August 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Solicitors on behalf of Stockport NHS Foundation Trust; 3) Weightmans LLP on behalf of North West Ambulance Service, who may find it useful or of interest. ; 2) 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 Alison Mutch HM Senior Coroner 20.06.2023 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 Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU Ms Alison Patricia Mutch OBE HM Senior Coroner for the Coroner Area of Greater Manchester South Coroner's Court 1 Mottram Street Mount Tabor Stockport SK1 3AG Dear Ms Mutch, 2 May 2024 Thank you for your letter of 20 June 2023 to the Secretary of State for Health and Social Care about the death of Joan Mary Corcoran. I am replying as I am replying as Minister with responsibility for urgent and emergency services. Please accept my sincere apologies for the 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 Corcoran’s death, and I offer my sincere condolences to her family. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over long ambulance response times by North West Ambulance Service NHS Trust (NWAS). In preparing this response, Departmental officials have made enquiries with NHS England and the North West Ambulance Service Trust (NWAS) who have reassured me that regional performance is improving. 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 across is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf fiscal year. The plan this 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. 1 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 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 also have 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 2022- 23, a reduction of over 27%. NWAS average Category 2 response times were over 13 minutes faster, a 32% reduction. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the NWAS region were 32 minutes 51 seconds, and this is the second month in a row that handover time has improved. 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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