Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0221, written 25 Apr 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 Apr 2024 |
|---|---|
| Reference | 2024-0221 |
| Deceased | Richard Carpenter |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Western Ambulance Service NHS Foundation 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.
HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Victoria Atkins MP The Secretary of State for Health & Social Care 39 Victoria Street London SW1H OEU CORONER I am David Ridley, Senior Coroner for Wiltshire and Swindon 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. http ://www. legislation .gov .u k/u kpga/2009/25/schedu le/5/paraqraph/7 http://www.legislation .gov .uk/uksi/2013/1629/part/7 /made 3 INVESTIGATION and INQUEST On the 15 December 2021 I opened an Inquest into the death of Richard Carpenter who was born on the 18 February 1950 and who died at his home address during the early hours on the 1 December 2021 aged 71. His Inquest was finally concluded today (23 April 2024). At the final hearing Inquest, I found that the medical cause of death was: 1a. Haemothorax 1b. Bleeding from Site of Cardiac Surgery 1 c. Mitral Valve Replacement (November 2021) for Severe Mitral Regurgitation In relation to the when, where and how Richard came by his death, I recorded as follows: "Richard underwent elective complex heart surgery on 19 November 2021 that included a Mitra/ Valve repair and also a single vessel Coronary Artery Bypass Graft. He was discharged home on 28 November 2021. Late evening on 30 November 2021 he developed pains down his left side. He became unresponsive during the early hours on 1 December 2021 and was confirmed dead at home at 0500 the same day. He died as a consequence of a complication following surgery when he developed a bleed more likely than not from the surgical site ." My conclusion as to Richard's death was that it was an ACCIDENT. 4 CIRCUMSTANCES OF THE DEATH As you will see from what I recorded on the Record of Inquest, Richard underwent elective major cardiac surgery in Bristol on 19 November 2021 and was discharged home on the 28 November 2021. Late evening on the 30 November 2021 he developed increasing pain down his left side and shortly after 22:30 that evening his wife made the first of a number of calls to the ambulance service. Although Richard was categorised as a CAT 2 response records show that an ambulance did not arrive at Richard's home address until 04:11 on the 1 December, some 5 Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP hours 34 minutes and 36 seconds from the time of the first call by which time Richard was unresponsive and despite advanced life support his death was confirmed at 05:00 the same morning. You will of course be aware that the target response time for a Category 2, I understand, is 18 minutes. At the final hearing I admitted evidence under Rule 23 of Coroners' (Inquests) Rules 2013 from who undertook the cardiac surgery on Richard in November 2021 and his evidence was that even if Richard had been got to hospital within say an hour of the original call the outcome would only have possibly been more favourable and the use of the word possibly does not meet the level of certainty that is required to establish causation which works on a balance of probabilities. CORONER'S CONCERNS 5 During the course of the Inquest I heard evidence from the Southwest Ambulance Trust from who is the Deputy Head of Clinical Operations in Safety and he explained in detail the pressures that all ambulance trusts were under at that particular time and he also explained new ways of working with a view to reducing the number of outstanding unallocated calls including the use of the National Model for Clinical Navigation and the use of ambulance personnel at hospital in an attempt to free up ambulances although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover. The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the as to whether or not the Trust is hitting its targets in relation to ambulance question to response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community. This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard's death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion. What is also of a concern is that what used to be considered seasonal pressures on ambulance services during the winter months is now becoming an all year round norm. As previously stated in other recent Regulation 28 Reports addressed to you any solution to the overall issues affecting the NHS will relate to matters of Government policy and resourcing. I am sure that the family here would appreciate an indication as to the national strategy here to address this issue over and above providing additional funding which tends to be the general response that, in my experience, is the usual reply. 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 20 June 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. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPI IDP 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Family of the Deceased , South Western Ambulance Service, NHS Foundation Trust 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. Dated 25 April 2024 Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPI IDP
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 Minister of State for Care 39 Victoria Street London SW1H 0EU 14 June 2024 HM Coroner David Ridley Wiltshire & Swindon Coroner’s Office 26 Endless Street Salisbury Wiltshire SP1 1DP Dear Mr Ridley, Thank you for your Regulation 28 report of 25 April to the Secretary of State for Health and Social Care regarding the death of Richard Carpenter. I am replying as Minister with responsibility for urgent and emergency care services. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Carpenter’s death, and I offer my sincere condolences to his family and loved ones. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention. Your report raises concerns over ambulance response times in the South Western Ambulance Service NHS Foundation Trust (SWAST) region and a relationship with availability of hospital beds linked to delays in discharging patients. You have appropriately shared your report and concerns with SWAST, who are best placed to respond on the specific action they are taking locally with NHS system partners to reduce handover delays and improve ambulance response times. In January 2023, NHS England published a two year ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, with a target for this year to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at: https://www.england.nhs.uk/publication/urgent-and-emergency-care- recovery-plan-year-2-building-on-learning-from-2023-24/ Your report highlights that SWAST were responding to high demand. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024. Since publication of the recovery plan in January 2023, there have been 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. There have also been improvements in handover delays with SWAST handovers almost 20 minutes faster on average in April than October 2023 (information on ambulance handover times has been published since October 2023). Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
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