Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0166, written 25 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Mar 2024 |
|---|---|
| Reference | 2024-0166 |
| Deceased | Robert Prowse |
| Coroner | Guy Davies |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Mental Health 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.
Information Classification: PUBLIC IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF ROBERT ANDREW PROWSE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Victoria Atkins MP, Secretary of State for Health & Social Care 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 25 September 2023 I commenced an investigation into the death of Robert Andrew PROWSE. The investigation concluded at the end of the inquest on 18 March 2024. The medical cause of death was found to be as follows: 1a. Urosepsis 2 Frailty of Old Age The four questions - who, when, where and how – were answered as follows: Robert Andrew PROWSE died on 19 September 2023 at Royal Cornwall Hospital Truro Cornwall from sepsis following an ambulance delay, attributable to a systemic failure, which is likely to have contributed to Robert’s death by preventing lifesaving treatment. The conclusion of the inquest was that Robert died from sepsis contributed to by an ambulance delay, attributable to a systemic failure, which likely prevented lifesaving treatment. 1 Information Classification: PUBLIC 4 CIRCUMSTANCES OF THE DEATH Robert was 86 years old at the date of his death. His medical history included a diagnosis of dementia. In the early hours of 19 September 2023 Robert’s neighbour called 999 on his behalf advising that Robert had been found breathing but not conscious, and it looked like he had had a seizure. Following the 999 call South West Ambulance Service Trust (SWAST) determined a Category 2 response requirement. Category 2 identifies potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. The national response time as set by the Department of Health is to attend Category 2 incidents within an average response time of 18 minutes, and at least 90% of incidents within 40 minutes The ambulance arrived on scene after a delay of three hours and 47 minutes from the time of the original 999 call. The ambulance arrived at Royal Cornwall Hospital Truro (Treliske) but it was not possible to transfer Robert to the emergency department (ED) due to the lack of available space. The court heard evidence of crowding within ED which included patients being placed in corridors. Robert was instead taken from the ambulance to a triage centre adjacent to Treliske ED. The triage centre is known as the Rapid Assessment and Treatment Centre. There it was noted that Robert displayed evidence of sepsis but it was determined that his condition was not immediately life threatening. Robert was given fluids but not antibiotics and then returned to the ambulance parked outside ED. Robert remained in the ambulance attended by the paramedic crew until later transfer to ED at 11:05 hours. The delay in handover between ambulance and Treliske ED was one hour, 25 minutes. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Robert was then subject to tests and sepsis was identified. Robert was found deceased at 13:00 hours. Antibiotics had been prescribed but Robert died before they could be administered. that the ambulance delay, including response The court heard evidence from delay and handover delay, likely contributed to Robert’s death. This is because earlier treatment of sepsis is likely to avoided Robert’s death. treatment of sepsis by way of oxygen, antibiotics and fluids, saves lives and improves outcomes. In Robert’s case earlier treatment is likely to have made a difference to the outcome. stated that early The court found that the categorisation of the call by ambulance services was appropriate. The court found that the delay was not caused by any individual failing but was attributable to a systemic failure discussed in the concerns set out below. 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. – 2 Information Classification: PUBLIC 1. Robert’s death followed an ambulance delay, attributable to a systemic failure, which is likely to have contributed to Robert’s death by preventing lifesaving treatment. 2. The systemic failure was found to be due to issues within healthcare services external to SWAST and notwithstanding increases in SWAST staff numbers and ambulance numbers. 3. Performance data published by SWAST and considered at Inquest, reveals that in 2023 the two hospitals (in the SWAST region) most impacted by ambulance delays are Royal Cornwall Hospital Truro (Treliske) & University Hospital Trust Plymouth (Derriford). These are the two hospitals servicing patients in Cornwall. 4. The court heard that at the time of the ambulance delay that contributed to Robert’s death, SWAST had 136% resources available to meet anticipated demand. The increased resources were not able to overcome the systemic failures impacting SWAST. 5. The court considered the findings in the SWAST Patient Safety Incident Investigation Report & an associated investigation conducted by the Healthcare Services Safety Investigation Branch (HSSIB). These investigations found that… ‘…there is a direct link between patients waiting in the hospital for discharge to social care, and patients being cared for inside ambulances and Emergency Departments.’ 6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge. 7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity. 8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. 9. The court heard evidence that Treliske have established a triage centre in the car park, known as the Rapid Assessment and Treatment Centre. The primary purpose of triage is to identify those patients in immediately life-threatening condition. The triage centre is an attempt to mitigate the risks due to ambulance delay and overcrowding in ED. stated that the vast majority of patients are now seen in the car park, inside ambulances or in the triage centre, rather than in ED. 10. The court heard evidence of crowding at Treliske ED with patients being accommodated in the corridors. Evidence was heard from scientific study by Royal College of Emergency Medicine (published in the Emergency Medicine Journal). This study discussed the adverse impact of crowding in ED. The study calculated the estimated number of excess deaths occurring across the United Kingdom associated with crowding and extremely long waiting times. The study showed that for every 72 patients waiting between eight- regarding a 3 Information Classification: PUBLIC and 12-hours from their time of arrival in the Emergency Department there is one patient death. 11. The court heard evidence that in September 2023 patients had spent a total of 14,327 hours in Treliske ED when it was clinically appropriate for these patients to be discharged or moved to a ward. This period of time is equivalent to closing 19 cubicles in Treliske ED for a whole month. Treliske ED has 26 cubicles. 12. The build-up of patients in the emergency department leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department. It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The investigation report stated: ‘’It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance’’. 13. The investigation report states ‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents. With fewer resources on the road, the response times to patients inevitably increases… ….The impact of the delays …is devastating¸ most significant¸ and most immediately evident to patients and their families and carers. Less evident is the secondary¸ detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.’’ 14. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts. 15. The court considered data for 2023 showing total operational resource hours lost to handover delays in excess of 15 minutes. The total lost by SWAST at Treliske was 35,583 hours. At Derriford the total lost in 2023 was 53,080 hours. 16. The court noted that two reports have been issued by this court in November 2023 addressed to the Health Secretary raised the same concerns regarding ambulance delays. A response to those reports is still awaited. 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, 4 Information Classification: PUBLIC namely by 20 May 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: the family, SWAST and Royal Cornwall Hospital Truro (Treliske). I have also sent a copy to University Hospital Trust Plymouth (Derriford), , and Cornwall Council 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. 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 25 March 2024 Guy Davies, HM Assistant Coroner 5
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 Helen Whately
Minister of State for Care
39 Victoria Street
London
SW1H 0EU
HM Assistant Coroner Guy Davies
Cornwall Coroners' Service
Pydar House, Pydar Street
Truro
TR1 1XU
22 May 2024
Dear Mr Davies,
Thank you for your Regulation 28 Report of 25 March to the Secretary of State for Health and
Social Care regarding the death of Robert Andrew Prowse. I am replying as Minister with
responsibility for urgent and emergency services.
Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Prowse’s
death and I offer my sincere condolences to his family. It is vital we learn from Regulation 28
reports where they raise matters of concern so NHS care can be improved. I am grateful to
you for bringing these matters to my attention.
Your report raised concerns about ambulance response times by South Western Ambulance
Service NHS Foundation Trust (SWAST), in particular how this is impacted by handover
delays and issues with discharging patients from hospital.
You have appropriately shared your report and concerns with SWAST and Royal Cornwall
Hospital Trust (RCHT), who are best placed to respond on the specific action they are taking
locally to reduce handover delays and improve ambulance response times.
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 ambition for this year is to reduce
Category 2 ambulance response times to 30 minutes on average. 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 SWAST were responding to high demand at the time of this sad
event, affecting the service provided to Mr Prowse.. 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.
1
Your report also highlights that Royal Cornwall Hospital was experiencing high demand with
long handover delays. I recognise that ambulance trusts work within a health and care system
and issues such as delayed patient handovers to hospitals, as you rightly identify in your
report, 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. We have 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 12,000 beds available nationally.
We are also investing an additional £1 billion this year through the Discharge Fund, to support
the NHS and local authorities to ensure timely and effective discharge from hospital. This
funding follows £600 million last year and £500 million in 2022/23. The NHS and local
authorities are using this funding to help provide people with the right care in the right place
when they are discharged from hospital. We have also ensured every acute hospital has
access to a care transfer hub, bringing together professionals from the NHS and social care
to manage discharges for people with more complex needs who need extra support with a
view to promoting early planning and timely discharge. These measures are helping improve
patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly
get back on the roads.
SWAST, NHS Cornwall and the Isles of Scilly ICB, and NHS Devon ICB are all in Tier 1 for
support for their urgent and emergency care performance. This means that NHSE provides
bespoke support to them to help improve performance and reduce variation with issues such
as handover delays.
The report referenced University Hospital Trust Plymouth being one of the most impacted by
ambulance delays in the SWAST region. In the longer term, a new emergency care hospital
for the University Hospitals Plymouth NHS Trust will be delivered by 2030 as part of the New
Hospital Programme. This will improve services by providing a new integrated emergency care
hospital, bringing all urgent care into one emergency care hospital, with dedicated areas for
children and frail patients. Further, locally Cornwall Partnership NHS Foundation Trust
received £3 million in 2023/24 as part of £250 million of capital funding provided nationally to
help increase NHS urgent and emergency care capacity.
Since publication of the recovery plan in January 2023, we have seen significant
improvements in performance. Nationally 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%. For SWAST, average
Category 2 response times were over 26 minutes faster over the same time period, a 38%
reduction. Regarding handover delays in SWAST, there has been notable improvement with
handovers almost 20 minutes faster on average in April than October 2023 (information on
ambulance handover times has been published since October 2023). At Royal Cornwall
Hospitals NHS Trust which RCHT sits, 4-hour trust performance of patients being admitted,
transferred, or discharged within four hours of arrival was 79.0% by April 2024. This is 4.6ppt
higher than the national average in this period.
However, I recognise there is still more to do to reduce patient 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.
Yours,
HELEN WHATELY
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