Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0357, written 29 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2023 |
|---|---|
| Reference | 2023-0357 |
| Deceased | John Winsworth |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care, The Rt Hon Steve Barclay MP And The Department of Health and Social Care 1 CORONER I am Jacqueline Lake, Senior Coroner for the coroner area of Norfolk. 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 24 February 2023 I commenced an investigation into the death of John Trevor WINSWORTH aged 92. The investigation concluded at the end of the inquest on 25 September 2023. The medical cause of death was: la) lb) le) 2) Traumatic Intracranial Bleed Fall Atrial Fibrillation (on Warfarin) The conclusion of the inquest was: Accident 4 CIRCUMSTANCES OF THE DEATH Mr Winsworth was found on the floor at his home on 14 February 2023. Emergency services were called at 11.55 hours. An ambulance arrived at 09.30 on 15 February 2023 and Mr Winsworth was taken to Norfolk and Norwich University Hospital, arriving at 10.52 hours. He was admitted to Accident and Emergency Department at 14.42 hours. A CT scan showed a small bleed in the brain and Mr Winsworth's Warfarin medication was stopped and he was given Vitamin K to promote clotting. Mr Winsworth was not referred to the Haematology Department in accordance with internal protocol, when it is probable medication to promote blood clotting within a shorter space of time would be prescribed. Mr Winsworth was assessed as fit to be discharged following examination and assessment. He was unable to get into a motor car and hospital transport was arranged. Mr Winsworth was returned to the ward. His condition suddenly deteriorated and he died on 21 February 2023 in hospital. 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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. The ambulance service was called at 11.55 hours on 14 February 2023 and the call was araded as a Cateaorv 3 call reauirina a resoonse within 2 hours. The ambulance Regulation 28 - After Inquest Document Template Updated 30/07/2021 arrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours. 2. The ambulance arrived at the Norfolk and Norwich University Hospital at 10.52 hours and Mr Winsworth was not able to be admitted to Accident and Emergency Department until 14.42 hours; over 3 hours following admission, due to pressure on the hospital. 3. Considerable delays in attendance by EEAST (East of England Ambulance Service Trust) to calls continues. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE Your organisation is under a duty to respond to this report within 56 days of the date of this report, namely by November 24, 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: • - son I have also sent it to: • East of England Ambulance Service Trust • Department of Health • Care Quality Commission • Healthwatch Norfolk • HSIB • NHS England and NHS Improvement who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 29/09/2023 _jbµ_ Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NRl 2DH Regulation 28 - After Inquest Document Template Updated 30/07/2021
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 HM Coroner Jacqueline Lake Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH 17 May 2024 Dear Jacqueline, Thank you for the Regulation 28 report to prevent future deaths of 29/09/23 about the death of John Winsworth. I am replying as Minister with responsibility for urgent and emergency case services. Firstly, I would like to say how saddened I was to read of the circumstances of John Winsworth’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for significant delay in responding to this matter. Your report raised concerns about ambulance response times, handover delays, and A&E waiting times. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. I am also aware you have written directly to the East of England Ambulance Service Trust (EEAST). My officials have advised me that the EEAST have taken the following actions taking to work with the integrated care system to reduce the impact of delays and reduce patient harm, including but not limited to: • EEAST are a member of the “Front Door Group” looking to improve arrival to handover times. This is chaired by the Deputy Director for Intensive Support from the NHSE/I team. EEAST have shared good practice from West Suffolk and Colchester Hospitals within the group, which is attended by all Acutes in the area. EEAST have also approached each Acute to review the current process and suggested changes to allow quicker offloads. • EEAST have implemented the unscheduled care coordination with the Integrated Care Board, Integrated Care 24 and community teams and have increased referrals into these teams through enhanced triage. This has also supported crews on scene, and this will strengthen their conveyance rate across Norfolk and Waveney as being consistently the lowest in the trust. • EEAST has also been involved in an ‘Improvement Week’ from 9 – 13 October 2023 in Norfolk and Waveney. The medical teams have been working alongside crews, dispatchers, and call handlers to better understand the issues behind delays for patients and helping identify ways to resolve them. This week will be run as a continuous improvement exercise and will use quality improvement approaches to capture real time information and potential solutions to the challenges they face. As the Minister responsible for urgent and emergency case 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 this fiscal year. The plan is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf. Your report highlights that EEAST were under high demand at the time of the incident. Alongside the local actions outlined above, 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. 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, year-to-date average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were almost 15 minutes faster compared to the same period last year, a reduction of over 27%. EEAST average Category 2 response times were over 23 minutes faster compared to the same time period last year, 34% faster. 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. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
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.