Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0256, 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 | 2023-0256 |
| Deceased | Thelma Radmore |
| 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: 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 30th December 2022 I commenced an investigation into the death of Thelma Mary Radmore .The investigation concluded on the 22nd May 2023 and the conclusion was one of Narrative: Died from a combination of Influenza A and Covid Pneumonitis contracted whilst an in-patient contributed to by an unstageable sacral pressure ulcer that was exacerbated by a prolonged wait for an ambulance and a prolonged wait for treatment and a bed in the Emergency Department. The medical cause of death was 1a) Influenza A and Covid Pneumonitis; II) Ungradable Sacral Pressure Ulcer, Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease 4 CIRCUMSTANCES OF THE DEATH Thelma Mary Radmore had a complex medical history. She was taken to Stepping Hill Hospital on 11th December 2022 at 18:20 via ambulance following a prolonged delay waiting for an ambulance to become available. Due to the volume of patients at the Emergency Department Mrs Radmore waited for over an hour with the ambulance crew in a corridor on an ambulance trolley. She was then moved to a hospital trolley in a cubicle. She was in the Emergency Department for in excess 26 hours before being transferred to a ward this was due to demand for and availability of beds. On the balance of probabilities the prolonged wait for a hospital bed and delayed transfer to hospital contributed to a significant deterioration in her skin integrity. Her sacral pressure ulcer was found to be unstageable on assessment by the tissue viability nurse on 16th December 2022. On 20th December 2022 she was swabbed for Covid-19 and Influenza A. Both on balance of probabilities contracted in hospital. She was initially stable. On 22nd December 2022 she began to deteriorate rapidly with Covid Pneumonitis and Influenza A. She died at Stepping Hill Hospital on 23rd December 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 1 is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients; 2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards; 3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage; 4. The inquest was told that the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally. 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) Stepping Hill Hospital, who may find it useful or of interest. on behalf of the Family and; 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 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.
From Helen Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU Ms Alison Patricia Mutch OBE HM Senior Coroner, Greater Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport, SK1 3AG 17 May 2024 Dear Ms Mutch, Thank you for the Regulation 28 Report to prevent future deaths of 19 July 2023 regarding the death of Thelma Mary Radmore. 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 Radmore’s death and I offer my sincere condolences to her family and loved ones. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful for you bringing these matters to my attention. The report raises concerns about ambulance response times in the North West of England, patient handovers to hospital, care for pressure ulcers and A&E waiting times. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE) and the Care Quality Commission (CQC). I have been reassured by North West Ambulance Service (NWAS) that 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, and I am pleased to note performance by NWAS has improved since this sad case. NHSE officials advise that action is being taken in Greater Manchester to improve urgent and emergency care performance including at Stepping Hill Hospital. The Greater Manchester (GM) Urgent and Emergency Care (UEC) programme sets out a plan to help reduce demand, improve capacity, transform services and improve productivity. Action is also being taken to improve local ambulance response times including through a joint handover plan between GM and NWAS and strategies to reduce conveyance. The CQC has also confirmed that they continue to have regular engagement with Stockport NHS Foundation Trust as well as NWAS to monitor waiting times performance and risk. Regarding the risks and treatment of pressure ulcers, I am advised that this remains a high priority for the trust with targeted training for staff. Initiatives include regular pressure ulcer review panels being held to discuss all incidents reported in every division of the hospital, and pressure ulcer verification masterclass delivered to senior nurses as required. I recognise the significant pressures the NHS is facing and the impact on waiting time for patients. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to drive sustained improvements in waiting times. Our ambition for this year is to improve A&E waiting times to 78% of patients to be admitted by March 2025, transferred, or discharged from A&E within four hours, and reduce Category 2 response times to 30 minutes on average in 2024/25. Regarding ambulance response times, 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. A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulance can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds 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. Same Day Emergency Care (SDEC) services will also be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided. Since publication of the plan, we have seen significant improvements in performance across the country. 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 previous year, a reduction of over 27%. In the Northwest of England, average Category 2 response times have similarly improved by over 13 minutes over the same period, a reduction of nearly third. We have also seen improvements in A&E waiting times this year – NHS data shows that 74.2% of patients were admitted, referred or discharged in 4 hours in March 2024 compared to 71.5% of patients in March 2023. However, I recognise there is still more to do to reduce response times and waiting times further, and the Government will continue to work with NHSE to achieve this. Thank you once again for bringing these concerns to my attention. HELEN WHATELY
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