Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0250, written 8 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2024 |
|---|---|
| Reference | 2024-0250 |
| Deceased | Bobilya Mulonge |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Secretary of State for Health and Social Care
1
CORONER
I am Lauren Costello, Assistant Coroner, for the Coroner Area of Manchester South
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 24th May 2023 an investigation was commenced into the death of Bobilya Mulonge
then aged 62 years. The investigation concluded at the end of the inquest on 19th April
2024. The conclusion of the inquest was a narrative conclusion that Mrs Mulonge died
as a result of congestive cardiac failure against a background of hypertensive
heart disease. Ambulance response times probably contributed to her death.
The medical cause of death being:
1 (a) Congestive Cardiac Failure
(b) Hypertensive Heart Disease
II) Chronic Kidney disease and Type II diabetes mellitus
1
4
CIRCUMSTANCES OF THE DEATH
Mrs Mulonge had multiple co-morbidities including hypertension with a history of
hypertensive crisis, stroke, diabetes and she had multiple hospital admissions in 2022.
On 24 November 2022 at 06:09 an ambulance was called because her breathing was
laboured, and her consciousness was reducing. During the call she became
unconscious. When an ambulance arrived 72 minutes later, at 07:24, she was in cardiac
arrest. Her heart was restarted but despite appropriate treatment she continued to
deteriorate and died at 10:45 on 24 November 2022 at Tameside General Hospital, as
a result of congestive cardiac failure against a background of hypertensive heart disease,
chronic kidney disease and type II diabetes mellitus.
The Inquest heard that the North West Ambulance Service was unable to meet average
response standards at the time of the 999 call mainly due to the fact that ambulances
were unable to clear the region’s hospitals because of the long waiting times there. In
addition, there were high call volumes. A level 4 incident plan was commenced as a
result.
A number of measures have been undertaken by the North West Ambulance Service to
address emergency response times including:
Regular meetings take place between the North West Ambulance Service and
NHS Trusts in the region to discuss the delays at a regional level.
There are faster communications between senior leaders in the North West
Ambulance Service and NHS Trusts when there is a period of high demand or
delay.
North West Ambulance Service managers are deployed to struggling Accident and
Emergency departments.
A delayed handover checklist is in place.
Patients are triaged to assess if they can wait in a waiting room to release
ambulances – this is called Fit to Sit.
Patients who can be safely grouped with other patients and looked after by one
ambulance crew rather than in individual ambulances are placed together to
release ambulances.
The North West Ambulance Service now has an option to remove crews with 15
minutes notice to the hospital.
Batch Divert is in place which allows the North West Ambulance Service to send
an ambulance to another hospital.
The inquest heard that waiting times across the North West region are still impacted by
problems clearing the regions hospitals despite the above measures.
2
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. –
Despite a number of measures being undertaken by the North West Ambulance Service,
the delay in paramedics attending Category 2 calls has not been resolved to within target
ranges. This is because resources available in the North West Ambulance Service
cannot be fully utilised as a result of the delays in ambulances clearing Accident and
Emergency departments.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
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 3rd July 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 namely 1)
on behalf of the family and;2) North West
Ambulance Service, who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
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.
9
Lauren Costello
HM Assistant Coroner
08.05.2024
3
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 3 July 2024 Our Ref: Lauren Costello HM Assistant Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG By email: Dear Ms Costello, Thank you for your letter of 8 May to the Secretary of State for Health and Social Care regarding the death of Bobilya Mulonge. I am replying as Minister with responsibility for urgent and emergency care. Firstly, I would like to say how deeply sorry I was to read the circumstances of Ms Mulonge’s death and I offer my sincere condolences to her 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 raised concerns about ambulance response times at North West Ambulance Service NHS Trust (NWAS) and that, despite a number actions being taken by the trust, response times are still being impacted by long patient handover times at A&E. In preparing this response, my officials have made enquiries with NHS England (NHSE) who have in turn liaised with Greater Manchester Integrated Care Board and NWAS. I am advised that NHS organisations locally are continuing work to support reductions in handover delays. A Hospital Handover Improvement Working Group continues to provide focus on this issue across Greater Manchester. Learning from the best performing trusts is shared across the region and a hospital handover Operational Improvement Plan has been developed with NWAS colleagues. This focusses on key areas including alternative options for conveyance, in particular direct referrals to Same Day Emergency Care, expanding and formalising Greater Manchester Falls response services and Urgent Community Response services to support further reduction in conveyance, and strengthening governance to improve risk reporting and escalation practices. As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the NHS is facing and the impact of waiting times for patients. In January 2023, NHSE published a two year ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times with targets for this year for a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025, and 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 1 continue to support systems to improve performance and reduce waiting times. The plan is available at: https://www.england.nhs.uk/wp-content/uploads/2024/05/PRN01288_ii_Delivery-plan-for- recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-2024.pdf Your report highlights that NWAS were under high demand at the time of the incident. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times. 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. £1.6 billion of funding was also made 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. At a national level, we have seen improvements in performance. 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%. NWAS average Category 2 response times were over 13 minutes faster in 2023/24 compared to the previous year, a 32% reduction. In May 2024, average patient handover times in the NWAS region were 31 minutes 30 seconds, over 7 minutes faster than January 2024. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY 2
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