Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0263, written 20 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 | 20 Jul 2023 |
|---|---|
| Reference | 2023-0263 |
| Deceased | Albert Dovey |
| 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 10th February 2023 I commenced an investigation into the death of Albert Dovey. The investigation concluded on the 30th June 2023 and the conclusion was one of Narrative: Accidental death exacerbated by underlying heart failure. The medical cause of death was 1a) Frailty; 1b) Rhabdomyolysis and fractured clavicle; 1c) Fall; ) II Heart failure, Acute kidney injury 4 CIRCUMSTANCES OF THE DEATH Albert Dovey had an accidental fall in his home address. He was found on the floor at his home address. He was admitted to Tameside General Hospital where he was found to have rhabdomyolysis. His oxygen requirement was significant. He had an acute kidney injury and required a blood transfusion. He had heart failure. He was treated with antibiotics. He was found to have fractured his clavicle which further reduced his mobility. He became gradually frailer as a consequence of his reduced mobility in combination with his heart failure despite treatment. On 4th February 2023 he died at Tameside General Hospital. 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 in relation to Mr Dovey there had been 1 delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital. The ambulance Mr Dovey was in a queue behind other ambulances waiting to unload patients into A and E. The inquest heard evidence that delays in treatment of elderly frail patients following a fall gave rise to an increased risk of death. In Mr Dovey’s case the delays were due to the sustained pressure on services across Greater Manchester which had been ongoing for months at the time of Mr Dovey’s death. The pressure was due to demand against availability of resources. 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 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 interest. , who may find it useful or of 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 21.07.2023 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.
Alison Mutch
Senior Coroner
Greater Manchester South
Coroner’s Court
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 – Albert Dovey who died on
4 February 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 July
2023 concerning the death of Albert Dovey on 4 February 2023. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Albert’s family and loved ones. NHS England are keen to assure
the family and the coroner that the concerns raised about Albert’s care have been
listened to and reflected upon.
In your Report you raised concerns about the delays for ambulances to be processed
at Tameside General Hospital’s Emergency Department (ED). This was due to
pressures on Greater Manchester services which was impacting on handovers
between ambulances and ED’s. You raised that the impact on these delays on elderly,
frail people, following a fall, such as in Albert’s case, gave rise to an increase in death.
In preparing this response, NHS England has engaged with NHS Greater Manchester
(NHS GM) as well as our National Ambulance Team.
It is not clear from your Report the date that North West Ambulance Service (NWAS)
attended at Albert’s home address but I note that he sadly died on 4th February 2022
following deterioration after his fall, which was within a period of documented extreme
pressure within the North West region. In response to the harm identified in the winter
period, NWAS and commissioners shared an analysis of high-risk incidents with the
wider system to stimulate reflection and discussion as to how all partners could
improve safety. This particularly related to the delays seen in hospital handover. The
work of
the North West and
improvements have been seen, especially within the area of your coroner’s office,
Greater Manchester, achieving the national target of 30 minutes in June and July 2023
with a monthly average of 29 minutes. The monthly average for hospital handover in
January 2023, was 40 minutes and 38 seconds for Greater Manchester, so significant
improvement has been achieved.
the handover collaborative continues across
NHS England recognises the significant pressure on ambulance services since the
Covid-19 pandemic, which has seen longer response times across all categories than
before the pandemic, as well as issues associated with handing over ambulance
patients in a timely way at some NHS Trusts and the flow of patients in and out of
some NHS Trusts. That is why NHSE 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 (UEC) 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.
Current performance levels in the North West have improved since the winter period
and started improving at the beginning of this year. The monthly average response
time in January 2023 for NWAS for Category 2 mean was 29 minutes and 53 seconds,
so was achieving the UEC recovery plan target of 30 minutes, and in Greater
Manchester was in a better position achieving 24 minutes and 23 seconds. The
monthly average for July 2023 Category 2 mean performance in Greater Manchester
has seen further improvement achieving 21 minutes 42 seconds. These are far closer
to the Ambulance Response Programme’s (ARP) standards and we hope to see
further progress as the recovery plan is implemented.
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 ARP
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
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