Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0254, written 19 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2023 |
|---|---|
| Reference | 2023-0254 |
| Deceased | Evelyn Dutton |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | 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: NHS England 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 August 2022 I commenced an investigation into the death of Evelyn Mary Dutton. The investigation concluded on the 4th May 2023 and the conclusion was one of Narrative: Died from natural causes contributed to by complications of an accidental fall, poor nutritional status and complications of necessary medication. The medical cause of death was 1a) Multi-organ failure; 1b) Frailty; II) Multiple Duodenal Ulcers, Fracture left hip with Hemiarthroplasty, Poor Nutritional Status, Systemic Sclerosis 4 CIRCUMSTANCES OF THE DEATH Evelyn Mary Dutton had severe Systemic Sclerosis. She was admitted to Stepping Hill Hospital following an accidental fall at her home address. It was identified that she had fractured her neck of femur. She was operated on. Post-operatively her weight was found to be low and she was referred to the dietetics team. Her nutritional status remained compromised and an Nasojejunal (NJ) tube was sited on 21st July 2022. There was a delay in utilising the NJ Tube until 29th July. The NJ feeding was subsequently stopped due to concerns of aspiration and fluid overload. It was restarted on the night of 4th August. There was a significant electrolyte imbalance, probably due to refeeding syndrome due to the issues with nutrition. On 5th August the feeding via the NJ Tube was stopped due to episodes of vomiting of blood from her gastro intestinal issues including duodenal ulcers, identified in a series of gastroscopies, probably caused by steroid treatment. She continued to become increasingly frail. She deteriorated further and died at Stepping Hill Hospital on 13th August 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. The MATTERS OF CONCERN are as follows. – 1 1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day. Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available; 2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022. 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 13th September 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 1) Hospital, who may find it useful or of interest. on behalf of the Family and; 2) Stepping Hill 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 19.07.2023 2
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.
Ms Alison Mutch
HM Senior Coroner
Manchester South
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 September 2023
Re: Regulation 28 Report to Prevent Future Deaths – Evelyn Mary Dutton who
died on 13 August 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 July
2023 concerning the death of Evelyn Dutton on 13 August 2022. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Evelyn’s family and loved ones. NHS England are keen to assure
the family and the coroner that the concerns raised about Evelyn’s care have been
listened to and reflected upon.
In your Report you raised a concern over pressures on the ambulance service and the
pressures being experienced at Stepping Hill Hospital’s Emergency Department (ED),
which caused delays an ambulance responding to Evelyn following a fall, as well as
to her admission at ED.
NHS England recognises the significant pressure on ambulance services since the
Covid-19 pandemic, which has seen longer response times across all ambulance call
categories than before the pandemic, as well as issues associated with handing over
ambulance patients in a timely way as well as the flow of patients in and out of some
NHS Trusts. That is why NHS England are focusing on improving ambulance
performance for 2023/24, supported by the Delivery plan for recovering urgent and
emergency care services, published in January 2023. The plan outlines the actions
and steps that we are taking across England to recover and improve urgent and
emergency care services, including improving ambulance response times, increasing
ambulance capacity through growing the workforce, improving flow through hospitals,
speeding up discharges from hospitals, expanding new services in the community,
and taking steps to tackle unwarranted variation in performance in the most challenged
local systems.
In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and
Primary Care Networks titled Delivering operational resilience across the NHS this
winter. This also included focusing on improvements around Accident & Emergency
handover and ambulance handover times.
You also raised a concern over the delays transferring patients to hospital and wards
and the risks to health and wellbeing of elderly, frail patients, such as Evelyn, this
caused. NHS England’s services such as Urgent Community Response and Virtual
Wards, Enhanced Health in Care Homes, and the development of Proactive Care
services, are designed to offer support and timely access to alternatives to hospital
admission. Whilst Evelyn required acute hospital care for her hip fracture, these
improvements aim to reduce delays for those that do require urgent, inpatient care.
Measures are also in place to increase throughout in Intermediate Care (IC) to help
reduce delays in discharge from acute beds and speed up admission from ED.
NHS England has also engaged with Greater Manchester Integrated Care Board (GM
ICB) on the concerns raised in your Report. They have advised that at the time of your
concerns regarding Evelyn’s care, in June 2022, there was a period of documented
system pressure within the North West region. This was reflected in handover delays
at hospitals which then impacted ambulance availability in the region, and, in turn,
contributed to longer North West Ambulance Service (NWAS) response times. The
work of the North West Every Minute Matters Hospital Handover Collaborative, which
began in 2018, has seen improvements, particularly within Greater Manchester. In
June 2022, the average hospital ambulance turnaround times for Greater Manchester
were 41 minutes and 42 seconds. The considerable work that has been undertaken
across the North West region has resulted in Greater Manchester meeting the national
target of 30 minute response times to Category 2 call-outs by June 2023, achieving a
monthly average of 22 minutes and 48 seconds. Improvements have also been made
to Category 3 response times.
Within the North West, ambulance performance is reviewed regularly via the Strategic
Partnership and Transformation Board, a joint committee between NWAS and the
Integrated Care Boards in the region. We acknowledge that there remains work to be
done to improve NWAS performance but are committed to achieving the Ambulance
Response Programme’s standards in the region.
I would also like to provide further assurances on national NHSE work taking place
around the Reports to Prevent Future Deaths. All reports received are discussed by
the Regulation 28 Working Group, comprising Regional Medical Directors, and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around preventable deaths are shared across the NHS at both a national
and regional level and helps us pay close attention to any emerging trends that may
require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.