Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0212, written 26 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 | 26 Jun 2023 |
|---|---|
| Reference | 2023-0212 |
| Deceased | Ginger Wright |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Emergency services related deaths (2019 onwards) · Alcohol, drug and medication related deaths · Suicide (from 2015) |
| 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 Ginger Wright Otherwise Known as Mark Steven Wright A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Chief Executive Officer South East Coast Ambulance Service (SECAMBS) 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 Mr Wright was opened on 5 July 2022. The inquest resumed on 22 May 2023 and concluded on 6 June 2023. The medical cause of Mr Wright’s death was: 1a. Quetiapine Toxicity The inquest concluded with a narrative conclusion as follows: ‘On the night of 14 June 2022 or the early hours of the morning on 15 June 2022 Mr Wright took a deliberate overdose of his prescribed quetiapine medication at his home address. At the time he took the overdose he intended to take his own life. After he had taken the overdose he spoke to a friend on the phone and allowed her to call an ambulance for him. He also propped the front door open so that the ambulance would be able to gain access on their arrival. However, on the arrival of the ambulance crew Mr Wright was found to be deceased. His death was due to quetiapine toxicity.’ 5 CIRCUMSTANCES OF THE DEATH In the early hours of the morning on 15 June 2022 Mr Wright’s friend sent him a text message and Mr Wright called and told that he had taken quetiapine tablets and he wanted to die. managed to persuade him to let call an ambulance. rang 999 and informed the operator that Mr Wright At 04:58 was conscious and breathing but that he had taken an overdose. provided the details of what he had taken. Wright back and remained on the phone to him whilst they waited for the ambulance. At 05:26 thought that Mr Wright was now unconscious and she did not know if he was breathing or not. rang 999 again and reported that she then called Mr At 06:40 an ambulance arrived at Mr Wright’s address and he was pronounced deceased at 07:39. The court found that there was a delay from 05:10 onwards in carrying out an urgent clinical review of the first 999 call by staff at the Emergency Control Room at South East Coast Ambulance Service (SECAMB). Had a clinical review taken place at 05:10, the call would have been upgraded to 2 a Category 2 call with a target response time of 18 minutes from the original call. In fact, the call was not upgraded to a Category 2 call until called back at 05:26, and thereafter an ambulance did not arrive at Mr Wright’s address until 06:40, one hour and 14 minutes later. Whilst the above delays are clearly a matter of concern, the court was not persuaded that they materially contributed to Mr Wright’s death. The initial delay at 05:10 was due to individual error and therefore does not form part of the concerns which you are asked to address in response to this report. However, the subsequent delay, which occurred following the second 999 call at 05:26, was because SECAMBS was in Stage 4 of its Surge Management Plan, meaning that demand for the service was significantly outstripping available resources and the service was not capable of responding to calls within target timeframes. During the inquest the court heard evidence from Manager at SECAMBS Emergency Control Room. gave evidence that during the last reported quarter, namely January to April 2023, SECAMBS had been operating at Stage 4 of its Surge Management Plan for 11.71 per cent of the time. In the previous quarter of September to December 2022, the Trust had been operating at Stage 4 for 45.73 per cent of the time. Clinical informed the court that there were various reasons for SECAMBS being in Stage 4 of the Surge Management Plan on such a frequent basis, including lengthy waiting times to hand patients over to hospitals, insufficient staff numbers despite efforts to recruit both here and abroad, as well as high numbers of staff sickness. Whilst the reported figures indicate a notable reduction in the amount of time SECAMBS is spending in Stage 4 of the Surge Management Plan as compared with the latter half of 2022, it remains a matter of significant concern that the Trust is unable to respond to calls within target timeframes for 11.71 per cent of the time. 3 6 CORONER’S CONCERNS The MATTER OF CONCERN is: There is a risk of a future reoccurrence of the situation which arose on 14 June 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes. 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. Mr Wright’s family 10 Signed: ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 26th day of June 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 Care 39 Victoria Street London SW1H 0EU 1 May 2024 Anna Crawford Coroners' Court Station Approach Woking Surrey GU22 7AP Dear Ms Crawford, Thank you for your letter of 26 June 2023 to the Secretary of State for Health and Social Care about the death of Mr Wright. I am replying as Minister with responsibility for urgent and emergency services. 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 Wright’s death and I offer my sincere condolences to his family and loved ones. I am grateful for you bringing these matters to my attention. Your report raises concerns about ambulance response times by South East Coast Ambulance Trust (SECAmb). I note the trust have provided you with a comprehensive response on the action they are taking locally. 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 The report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery 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 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. 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. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings. 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 same period last year, a reduction of over 27%. In 2023-24, SECAmb performance has also improved and on average the trust’s Category 2 response times have been over 8 minutes faster than the national performance. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the SECAmb region were 18 minutes 41 seconds and is the fourth month in a row that handover time has improved. I also understand the time the trust has spent in surge level 4 has reduced across 2023. However, I recognise there is still more to do to reduce response times further and back towards pre-pandemic levels – improving NHS services and reducing waiting times is a key priority of this Government. Thank you once again for bringing these important issues to my attention. Yours, HELEN WHATELY
To: Ms A Crawford HM Assistant Coroner for Surrey Thursday, 10 August 2023 By email only 14 August 2023 Dear Madam Inquests touching the deaths of Mr Keith Nielsen and Mr Ginger Wright Thank you for providing SECAmb with an opportunity to submit the response to the prevention of future death reports, following the conclusion of the inquests for Mr Nielsen and Mr Wright. I was saddened to hear of these incidents, and I would like to offer my sincere condolences to the family and friends of Mr Nielsen and Mr Wright. I note your concern is that “SECAmb is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes”. South East Coast Ambulance Service NHS Foundation Trust (SECAmb) was commissioned in 2017-18 to provide the 999-emergency service across the three full counties of Kent, Surrey and Sussex, and only part of Hampshire (North-East Hampshire). The scope, size and structure of the service was commissioned based on a comprehensive demand and capacity review undertaken in collaboration with an external organisation based on data from previous years of delivery and planning assumptions. Prior to the Covid-19 Pandemic SECAmb was performing more favourably against Ambulance Response Programme (ARP) targets, however not consistently meeting all targets. Since early 2019 to the present day, there have been several notable changes in both the way that the public uses the service as well as how the service is operated as part of the wider healthcare environment. Both factors are included in the current development of a new Trust strategy which will be accompanied with a new care delivery model agreed by key stakeholders. The data shows that there has been a change in demand, and in the profile of patient types, with a significant increase in the proportion of higher acuity/more complex calls, requiring additional resource and clinical expertise. Factors contributing to this challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand. It is recognised that to support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across Integrated Care Systems (ICSs). With ICSs becoming legally established in July 2022, this has changed the way Health and Social Care providers work collaboratively and plan delivery of services to their populations, with an increasing focus on public health, improving performance against national and local requirements, and recognising the need for integrated strategies for key areas such as workforce (linked to the recently published NHS Long Term Workforce Plan). Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are: • Call handling – to achieve the ARP performance targets. • ARP Category 2 (C2) mean response time– in recognition of the national performance position, all ambulance trusts to deliver a C2 mean performance of a maximum of 30mins by the end of the financial year, • Hospital handover times – to deliver significant improvement to remove 60min+ handovers and reduce overall handover time and lost hours at hospital due to extended handover times. Whilst SECAmb will continue to focus attention to optimise performance within the current commissioned service, it is recognised that to deliver comprehensive and sustainable improvement a full system-wide review in conjunction with external stakeholders is required, which in turn will lead to a model of care delivery that addresses the current and future requirements of the public across Kent, Surrey, Sussex, and North-East Hampshire. If I can be of any further assistance, please do not hesitate to contact me. Yours sincerely Executive Director of Quality and Nursing (interim) on behalf of Simon Weldon Chief Executive Officer South East Coast Ambulance Service NHS Foundation Trust
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