Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0238, written 22 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 May 2023 |
|---|---|
| Reference | 2024-0238 |
| Deceased | Michael Bray |
| Coroner | Peter Taheri |
| Coroner area | Suffolk |
| Category | Emergency services related deaths (2019 onwards) · Suicide (from 2015) |
| Organisation named | East of England Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care 2) [The East of England Ambulance Service NHS Trust] 1 CORONER I am Peter Taheri, Assistant 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 15th October 2021 an investigation was commenced into the death of Michael James Francis Bray. The investigation concluded at the end of the inquest on 16th February 2023. The Jury’s narrative conclusion of the inquest was that: Michael Bray died by way of misadventure. Points that possibly contributed to Michael’s death include: • The Fast Action Response Plan, and whether it should have been updated to include risks arising from the near-miss on 23 September 2021 and PC Cook’s view by 4th October 2021 that the risks of suicide / misadventure had risen to high. • Whether the Police should have deployed resources upon learning, at about 2.02am on 10th October 2021, that Michael was no longer on the telephone to the mental health professionals together with the knowledge that an ambulance could take up to 120 minutes to arrive. • Whether the Ambulance Service should have asked Police to deploy a resource because of delays in sourcing an available ambulance. • The Ambulance Service omission to bring the Police declining to attend, at about 3.18am, to the attention of the Ambulance dispatcher, leading to a one- hour delay in the dispatcher becoming aware that Police would not attend. • The appropriateness of the ambulance crew’s dynamic risk assessment on arrival at Michael’s home address and their decision not to approach his house and check his door and check welfare. • The period of time taken for the ambulance crew to chase for the whereabouts of Police attendance. • The timing of any escalation of the Ambulance Service request for Police attendance. • Shortcomings in software and communication systems, amongst agencies • Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned. The sharing and agreement of actions, at times lacked urgency. • The police failing to complete a welfare check after an initial call from the Crisis Team. The medical cause of death was confirmed as: 1(a) Hanging 4 CIRCUMSTANCES OF THE DEATH The Jury’s answer to how, when, where and in what circumstances the deceased came by his death was: Michael Bray was at home on 9th and 10th October 2021 He had been drinking alcohol and called the Crisis Helpline stating resulting in his death sometime between 1:55-5:53, 10th October 2021 considering hanging himself. After the call, he proceeded, After the conclusion of the evidence, I ruled that on the evidence the Jury could not safely make any finding of fact on the balance of probabilities on the precise time of death other than that death occurred between about 1.50am and 5.53am on 10th October 2021. The Jury were directed to, and did, answer the question of when the deceased died accordingly. A notable feature of this case was a lack of availability or provision of an ambulance to respond in a timely manner to the deceased’s Category 2 call, which contributed to a considerable delay. On the evidence, the national ambulance target response time for a Category 2 call is an average of 18 minutes, with 90% of calls to be responded to within 40 minutes. In this case, the ambulance response took a period of time in the hours, considerably greater than the target response time. 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 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: – Although it could not be safely said when the deceased died, and therefore it could not safely be said that the delay in the ambulance response probably contributed to the death, the concern is that long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future. Bearing in mind the national ambulance target response time for a Category 2 call of an average of 18 minutes, with 90% of calls to be responded to within 40 minutes: The average Category 2 response time for the East of England Ambulance Service NHS Trust (‘EEAST’) in October 2021, the month of this death, was 56 minutes and 2 seconds. The same average time for January 2023, the most recent month for which data was available, was 49 minutes and 3 seconds. Every month since the deceased’s death, EEAST’s Category 2 response time has been above the 90th centile time of 40 minutes. The average EEAST Category 2 response time for a given month in the period from October 2021 to January 2023 is over 1 hour, with a standard deviation of about 20 minutes. Therefore, EEAST’s Category 2 response time remains persistently and consistently far off target. Although I accept on the evidence that action is being taken, on both local and national levels, to prevent future deaths as a result of this issue, the evidence of the results of such actions to date is that these actions have been demonstrably ineffective and have not resulted in a Category 2 average response time for EEAST that is even close to the target time. The evidence received was that this issue, and the causes for it and the action required, are not just local in nature, but also national. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you and / or your organisations 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 17th July 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: - The Bray Family (in particular , the deceased’s son, and , the deceased’s wife) - - The Chief Constable of Suffolk Constabulary - Norfolk & Suffolk NHS Foundation Trust I am 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 22nd May 2023 Peter Taheri
2 responses 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 Peter Taheri Assistant Coroner for the coroner area of Suffolk BMSDC Endeavour House Ipswich IP1 2BX 12 April 2024 Dear Mr Taheri, Thank you for your letter of 25 May 2023 about the death of Michael Bray. I am replying as Minister with responsibility for Urgent and Emergency Care. Please accept my sincere apologies for the significant 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 saddened I was to read of the circumstances of Mr Bray’s death and I offer my sincere condolences to their family and loved ones. I am grateful to you for bringing these matters to my attention. Your report raises concerns about the ambulance response times by East of England Ambulance Service NHS Trust (EEAST). You have raised these concerns directly with EEAST which is best placed to respond on the specific action being taken locally to improve response times. In preparing this response, Departmental officials have made enquiries with the Care Quality Commission who have also met EEAST to discuss the circumstances around Mr Bray’s death and local action being taken. I recognise the significant pressure services are 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, including to reduce Category 2 response times to 30 minutes on average is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf this year. The plan 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 1 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 made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E, reducing delays in ambulances handing over patients so they 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 winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a 24% reduction. For EEAST, in winter 2023-24, average Category 2 response times were almost 23 minutes faster compared to the same time period last year, a 32% reduction. However, I recognise there is still more to do to reduce response times down further and back towards pre-pandemic levels – reducing waiting times is a priority for this Government. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY 2
HM Coroner Peter Taheri Assistant Coroner for Suffolk By Email 18 July 2023 Dear Mr Taheri, East of England Ambulance Service NHS Trust Headquarters Whiting Way Melbourn Cambridgeshire SG8 6NA I am writing further to the inquest into the death of Michael James Francis Bray, which concluded on 16 February 2023. I understand that you heard from a number of Trust witnesses during the inquest and the Legal Services Team provided you with additional information post-inquest in relation to the actions the Trust is taking to respond to Category 2 calls. Following this you made a Regulation 28 Preventing Future Death report and this is the Trust’s response to your concerns. You acknowledge that action is being taken on both local and national levels in relation to the C2 response times (as this is not an issue specific to this Trust) however you have stated that the evidence from these actions is that these have been ineffective to date. The Trust has an Organisational Performance and Improvement Plan (OPIP) where the main aim is to improve the Trust’s response to patients demonstrated in national performance benchmarking and to increase the work-effective workforce. The plan is incredibly detailed and identifies actions on a granular level, however the attached presentation has been produced to provide a visual update on where we are with this work. I believe this demonstrates the Trust’s commitment to improve our response times and the key areas of focus. Meeting the C2 response time has been a challenge for all ambulance services. Modelling by NHS England (NHSE) demonstrates there is a strong relationship between hospital handover delays and the ambulance C2 performance. NHSE’s regression model indicated that based on previous performance, in order to reach an average response time of 30 minutes for C2 patients, a maximum of 1,500 lost hours per week should not be exceeded (see graph below). Equally if more than 1,500 hours are lost per week, the C2 response time is unachievable. The Regional NHSE oversight meetings have been formed to support this important maximum standard. Currently levels exceed this significantly and in Q1 weekly lost hours exceeded 2,700 hours per week. www.eastamb.nhs.uk We are continuing to work with NHSE and our other healthcare partners to improve our response times, particularly in relation to Category 2 calls. Please do not hesitate to contact me should you require any further information. Yours sincerely, Chief Executive Officer www.eastamb.nhs.uk
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