Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0506, written 1 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2023 |
|---|---|
| Reference | 2023-0506 |
| Deceased | David Briggs |
| Coroner | Hannah Berry |
| Coroner area | South Yorkshire (Western) |
| Category | Emergency services related deaths (2019 onwards) |
| 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 THIS REPORT IS BEING SENT TO: 1. The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU 2. The South Yorkshire Integrated Care Board, 722 Prince of Wales Road, Sheffield, S9 4EU CORONER I am Hannah Berry, Assistant Coroner for South Yorkshire (West). 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 20 June 2023 I commenced an investigation into the death of David John BRIGGS. The investigation concluded at the end of the inquest on 30 November 2023. The conclusion of the inquest was that Mr David Briggs, died on 15 November 2022 at the Northern General Hospital, Sheffield from an infection resulting from catheterisation. The medical cause of death was: 1a. Urosepsis 1b. Urinary tract obstruction 1 2 3 1c. Spina bifida Mr Briggs had spina bifida with paralysis from the waist downwards and resided in supported living where he relied heavily on support staff for everyday living. He had a long term supra pubic catheter and colostomy and in early November 22 Mr Briggs's carers became concerned that his catheter wasn’t draining properly and with engagement with primary care Mr Briggs was prescribed antibiotics for a possible urinary tract infection on 12 November 2023. 4 At 2049 on 14 November Mr Briggs's carers called 999 as he was struggling to breath. The call was routed to Yorkshire Ambulance Service (YAS) who coded the call as a Category 2 (expected response within 40 minutes). At 2145 a second 999 call was made which was answered by East Midlands Ambulance Service (EMAS) having been routed by BT. This call was also coded as a Category 2 and passed to YAS. At 2219 a third 999 call was made and answered by YAS as Mr Briggs's breathing was worse and he was struggling to breath in- between talking. This call was again coded as a Category 2 At 2339 a fourth 999 call was made which was again answered by EMAS. This call was incorrectly coded as a Category 2 by EMAS, instead of a Category 1 and passed to YAS. At 0027 the final 999 call was made. Mr Briggs was unresponsive and not breathing. The call was coded as a Category 1 and carers advised to start CPR. The YAS ambulance arrived at 0044 and after initial treatment David was transferred to the Northern General Hospital in Sheffield where he was pronounced dead at 0231. 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. – 5 (1) The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022. (2) YAS were not resourced to respond to the number of emergency calls. 6 7 8 (3) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 January 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; - Mr Briggs's family - Yorkshire Ambulance Service, Brindley Way Wakefield 41 Business Park Wakefield WF2 0XQ - East Midland Ambulance Service, 1 Horizon Place, Mellors Way Nottingham Business Park Nottingham, NG8 6PY 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. 1 December 2023 9 Signature Hannah Berry H.M Assistant Coroner for South Yorkshire (West)
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 Hannah Berry Assistant Coroner for South Yorkshire (West) Medico Legal Centre Watery Street Sheffield S3 7ES 17 May 2024 Dear Ms Berry, Thank you for your letter of 1 December 2023 about the death of David John Briggs. I am replying as Minister with responsibility for urgent and emergency 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 Briggs’ 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 capacity of Yorkshire Ambulance NHS Trust (YAS). You have appropriately shared your report and concerns South Yorkshire Integrated Care Board, who are best placed to respond on the action being taken locally to improve ambulance response and patient handover times. 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 include reducing Category 2 ambulance response times to 30 minutes on average across this fiscal year. https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf available plan The at is Your report highlights that YAS 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. 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. At a national level, we have seen significant improvements in performance this year compared to last year. 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 27%. In the Yorkshire region, average Category 2 response times were over 9 minutes faster in 2023/24 compared to the previous year, a reduction of nearly 23%. 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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