Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0453, written 9 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2023 |
|---|---|
| Reference | 2023-0453 |
| Deceased | Christopher Hart |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | East of England Ambulance Service NHS Trust |
| 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 Right Honourable Steve Barclay MP Secretary of State for Health and Social Care House of Commons London SW1A 0AA 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 11 November 2022 I commenced an investigation into the death of Christopher Ivan HART aged 50. The investigation concluded at the end of the inquest on 27 October 2023. The conclusion of the inquest was that: Narrative Conclusion The medical cause of death was confirmed as: 1a Coronary Artery Atherosclerosis 1b 1c 4 CIRCUMSTANCES OF THE DEATH On the 25th October 2022 Christopher Hart was declared deceased at his home address of 30 Old Barrack Lane, Woodbridge in Suffolk. Christopher had become unwell at approximately 01:00 on 25th October 2022, and an ambulance was requested via a 999 call. Due to high service demand, and ambulances waiting to off-load their patients at the local hospitals, no ambulance was immediately available. The 999 call had been coded at Category 2 , with an average expected response time of 40 minutes, and a target attendance time of 18 minutes. At approximately 09:30 a family member visited Christopher’s home, finding him unresponsive and not breathing on the lounge floor. East of England Ambulance Service attended, but Christopher could not be resuscitated. His death was recognised at 09:35 on the 25th October 2023. A subsequent post-mortem examination identified that cardiac condition was responsible for Christopher’s death. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The delay in an ambulance attending meant that potentially life saving treatment could not be given, so that delay directly contributed to Christopher’s death. 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: (brief summary of matters of concern) Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region. These periods of non-availability (in this case of over 8 ½ hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself. Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Christopher’s each year, identified that had an ambulance for Christopher arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life. I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 January 04, 2024. 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 I have also sent it to East of England Ambulance Service NHS Trust who may find it useful or of interest. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 09/11/2023 Nigel PARSLEY HM Senior Coroner for Suffolk 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 Minister Whately Minister of State for Social Care 39 Victoria Street London SW1H 0EU 17 May 2024 Our Ref: Nigel Parsley Senior Coroner The Coroner’s Court and Offices Beacon House Whitehouse Road Ipswich IP1 5PB By Email: Dear Mr Parsley, Thank you for your letter of 9 November 2023 to the Secretary of State for Health and Social Care regarding the death of Christopher Hart on 25 October 2022. I am replying as Minister with responsibility for urgent and emergency care services. Please accept my sincere apologies for the 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 deeply sorry I was to read the circumstances of Mr Hart’s death and I offer my sincere condolences to his family. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful to you for bringing these matters to my attention. Your report raised concerns about the pressures faced by East of England Ambulance Service NHS Trust (EEAST) and ambulance response times in Suffolk. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE advise officials that EEAST is implementing an Operational Performance and Improvement Plan locally to improve efficiency and maximise ambulance availability. EEAST isundertaking additional recruitment to increase the number of frontline clinicians, and also increase the clinical triage of calls to ensure that patients can be transferred to alternative services where appropriate, helping reduce demand on the ambulance service. This has been supported by the establishment of an Unscheduled Care Coordination Hub 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 on average across this year. The plan is available at https://www.england.nhs.uk/wp- 1 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. 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 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. We have also implemented a new tiering performance and improvement approach to support challenged ambulance trusts and wider systems. There is support in place at national and regional level to support Tiers 1 and 2 with EEAST in Tier 2 with a universal improvement support offer being made available for all systems. 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. Since publication of the plan, we have already seen significant improvements in performance this year at a national level. At a national level 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 East of England, average Category 2 response times were over 23 minutes faster over the same time period, a 34% reduction. In March 2024, average patient handover times in the East of England were 32 minutes 51 seconds, nearly 12 minutes faster than in October 2023 (since this information has been published). 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
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