Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0275, written 20 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 | 20 May 2024 |
|---|---|
| Reference | 2024-0275 |
| Deceased | Sylvia Evans |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (2019 onwards) |
| Organisation named | Welsh Ambulance Service NHS 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.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 4 THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board. CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 18/09/2023, an investigation was opened touching upon the death of: Sylvia Eileen Evans The investigation concluded at the end of the inquest on 14/05/2024 The conclusion of the inquest was recorded as: Death by Accident. The medical cause of death was: 1a) Ischaemic heart disease 1b) Coronary Artery Disease 1c) 2 Blood loss from leg wound. Atrial Fibrillation (on anticoagulants) CIRCUMSTANCES OF THE DEATH On 05/09/2023, Sylvia Eileen Evans sustained an accidental wound to her leg at home, which caused a severe haemorrhage. This in turn put pressure on her heart, the function of which was already compromised by extensive ischaemic heart disease. The effects were overwhelming and resulted in Sylvia’s death on 06/09/2023 at her home address. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - Sylvia Evans suffered an injury to her leg which caused extensive blood loss. At 22:56 hours she called for an ambulance. The call ended abruptly, and the inquest determined that Sylvia was bleeding heavily and suffering the effects of heart failure exacerbated by severe haemorrhage, which caused her to end the call. The nature of her injuries had not been conveyed to the call handler. The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people wo are likely to be suffering from a life- threatening emergency. An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylivia had died by the time the ambulance arrived. The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Welsh Ambulance Service NHS Trust identified a number of initiatives they have implemented over the last few years to try and address the problem of long waits in the community. However, they are unable to influence what happens at a hospital where, repeatedly, ambulances are waiting for extended periods of time because patients cannot be moved into the Emergency Department. I should be grateful if the following information be provided to me: The problems with ambulance delays commenced during the Covid pandemic, and this court has previously been made aware of the action taken to address the problem of patient flow. However, the problem does not appear to be abating and I should be grateful if you would provide me with details as to how this is being addressed and future deaths avoided. Whilst there was insufficient evidence to determine that an earlier ambulance response would have saved Sylvia’s life, clearly waiting extended periods of time are putting patients’ lives at risk. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 15 July 2024. I, the Coroner, may extend this period. 8 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 necessary COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Sylvia Eileen Evans • Health Inspectorate Wales • Welsh Ambulance Service NHS Trust • Minister of Health for Wales 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 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 DATE 20/5/2024 Signed: Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
, Cadeirydd | Chair , Prif Weithredwr | Chief Executive Our ref: NP/nr Caroline Saunders Senior Coroner (Gwent) Via email: Dear Ms Saunders Monday 15th July 2024 Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Sylvia Evans which concluded on 14 May 2024. Thank you for your Regulation 28 Report dated and received by the Health Board on 20 May 2024. I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, which was issued following the inquest into the death of Sylvia Evans. As requested, the information presented below is intended to describe the actions which have been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths. It is acknowledged that the Health Board was experiencing handover delays at all of its sites on this day. During the previous days, all hospitals within the Health Board and indeed, neighbouring Health Boards and all Health Boards across Wales experienced delays that were in excess of the 15 minutes standard as stipulated in the Welsh Health Circular (May 2016). The days leading up to the incident on 5 September 2023 saw very high attendances at the Grange University Hospital (GUH) with activity on 5 September being the second highest during that week which placed significant additional pressure on services, particularly within the Emergency Department (ED). The management team have a number of processes in place to improve flow. Therefore, the pressures at the front door and leadership on a day-to-day basis for GUH was managed by the Corporate Site Operations Team who ensured that where delays were being experienced that the Health Board’s ‘Emergency Pressures Escalation Policy’ is actioned. This document provides clarity on the responsibilities of a wide range of Health Board colleagues including the Emergency Department, Operational Site Managers, Senior Divisional Leadership Teams and Executive Directors and the actions Bwrdd Iechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ Aneurin Bevan University Health Board Headquarters, St Cadoc’s Hospital Lodge Road, Caerleon, Newport NP18 3XQ Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi. Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan. We welcome correspondence in Welsh and we will respond in Welsh without delay. Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board. that must be taken to reduce ambulance delays, in particular, and wider system pressures. Recent initiatives to improve patient flow and subsequent ambulance handover delays saw the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following workstreams: 1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include: a. Consultant presence in the Flow Centre to aid senior clinical decision making b. Redirection for specific conditions to eLGH sites rather than the GUH for more appropriate and rapid assessment and treatment c. Falls response in the community 2. Emergency Department/Assessment Area Focus a. Revision of the escalation framework to ensure that the points of escalation during any ambulance handover delays are appropriate b. Creation of inter-speciality standards c. Prioritisation and assessment of the balance of risk 3. Discharge Logistics a. Focussing on how the Health Board can better utilise its discharge lounges to provide an immediate and early pull from wards across all sites to create capacity to support ambulance handover times b. Improving how the internal process for the handover of patients who are transferred from the GUH to the eLGH sites In April 2024, the Health Board was placed under ‘Enhanced Monitoring’ by the Welsh Government for its Urgent Care services with an inception meeting with our Executive Team on 9 April. There are now three key areas of improvement that are monitored and reported back to the Welsh Government: 1. Three-month continuous reduction of at least 15% each month (from Oct-Dec baseline) for ambulance handovers 2. Continuous improvement towards no more than 5% of patients waiting over 12 hours at each individual site and across the Health Board 3. 100% of patients to be assessed by a senior clinical decision maker within 60 minutes from arrival To support these key areas of improvement, further support has been provided to the Urgent Care Division to ensure that the managerial capacity to plan and implement required changes is facilitated. This has included: 1. Weekly review meetings with the Urgent Care Division chaired by the Chief Operating Officer and attended by the three Clinical Executive Directors (Medical Director, Director of Nursing & Director of Therapies and Health Science) and key Clinical Divisional colleagues. The purpose being: a. To provide a healthy challenge to current processes & procedures b. Review of weekly data to support the three key improvement areas c. Offer of support to ensure that the Urgent Care Division is working within a collaborative working environment with all other Clinical Divisions 2. A new post supporting the Chief Operating Officer’s team to enhance capacity and focus on the urgent care system daily operating and escalation where appropriate. 3. A number of priority developments being tested and considered as part of the improvement programme.: a. Substantive and increased provision of the Physician Response Unit (PRU). The PRU delivers community emergency medicine. It brings senior level decision-making to the scene and community, enabling best care to be delivered in a truly patient centred approach. In 2023, 68% of patients seen by the PRU remained at home, 31% streamed directly to a speciality. 97% of the PRU patients avoided the ED, this non- conveyance supports unnecessary attendance at our Emergency Department, subsequently assisting in the reduction of ambulance handover delays b. A new business case for additional ED Consultants to reduce clinical assessment times c. Further review of the clinical decision-making model within the Flow Centre, ensuring that best clinical advice is provided and that WAST colleagues are directed to the most appropriate receiving site We initially introduced these meetings as a dual-part format to address both the Urgent Care Emergency Department aspect and the broader operational approach, ensuring comprehensive coverage of all elements. This was further consolidated in June 2024 into a single session to embrace a holistic system-wide approach that will support this expanded method of working. All three key areas that require development have defined owners of actions and specific outcomes that are expected to support delivery of the required improvements. The Health Board is also fully engaged with the NHS Wales Six Goals for Urgent and Emergency Care programme which has been co-designed on a national basis by clinical and professional leads. This spans the urgent and emergency care pathway and reflects the priorities in the Programme for Government 2021 – 2026 to provide effective, high quality and sustainable healthcare as close to home as possible, and to improve service access and integration. The expectation is that adoption of nationwide best practice, including a local input into specifics will improve handover delays and reduce clinical risk. A number of priority workstreams are ongoing that have been instrumental in reducing handover delays within the Health Board. These have been streamed into three distinct workstreams: 1. Workstream 1 – Redesigning Services for Frail and Older People a. Development of a permanent acute frailty team to focus on this cohort of patients b. Redesign of the model for community hospitals including Direct Access beds c. Extending the Community Resource Team offer to support people with complex needs within the home d. Work with WAST on a Virtual Ward Model e. Greater support to Care Homes 2. Workstream 2 - Urgent & Emergency Care Redesign a. Improvements to the Same Day Emergency Care (SDEC) services established within GUH and YYF Hospitals, increasing patient selection which will release capacity for ED and Assessment Units. These services have seen a continued upward trajectory in medical patients since March 2023. b. Continuing of WAST’s ‘waiting stack’ reviews and continuing redirection of patients where deemed clinically safe and appropriate Improvements in WAST access to the Health Board’s Flow Centre c. Single phone number for Health Care Professionals to enable a smoother contact process with alternative services including community frailty and Urgent primary Care d. WAST referral line for agreed alternative to ED pathways within the Health Board to prevent direct ED attendances Initial scoping and commitment from the Health Board and WAST to create a collaborative working workstream, specifically looking at alternatives to hospital conveyance e. Review of Ambulatory Care pathways including respiratory and chest pain pathways f. Improvements in community falls including head injury and fractured neck of femur pathways g. Pilot of an Electronic Triage system within the ED and MIU department waiting rooms to improve efficiency and risk management 3. Workstream 3 - Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays a. Introduction of focussed patient safety events across all the key Health Board sites to improve discharge processes and number of patients waiting in hospitals for discharge to either home or another facility b. Creation of a discharge hub at the Royal Gwent Hospital jointly with social care c. Creation of a Ready to Go Ward and a discharge floor at the Royal Gwent to bring together a discharge lounge, the Ready to Go Ward and in integrated hub to manage patients transition more effectively to their own home d. Creation of a Hospital to Home service to provide additional support within the community e. A focused project at Nevill Hall Hospital working with Monmouthshire Local Authority focused on proactive discharge arrangements to people’s own homes WAST, in conjunction with the Health Boards operate an ‘Immediate Release Direction Protocol’ which outlines the principles and processes for the management of immediate release directions that includes a dynamic escalation process to, as far as possible, minimise patient safety risk for patients awaiting a response in our communities when ambulance capacity is reduced when the time for patient handover at emergency departments is extended (the handover standard is 15 minutes and considered extended beyond 30 minutes). During 5 September, whilst noting that the Health Board did have significant challenges with adhering to the nationally agreed 15-minute ambulance handover time, WAST did not contact the Health Board via approved routes to ask for a vehicle to be release d. The 999 call to attend to Mrs Evans had been coded as an amber 1 response and fell within the provision of the Immediate Release Direction Protocol. Had this occurred, the Health Board would have endeavoured, as per the protocol to release a delayed vehicle to respond as requested. Finally, I would wish to reassure you that the Health Board is rigorously focused on the reduction of ambulance handovers and the associated risk for patients that these delays create. In addition to the focused work referenced above the Chief Operating Office and the Clinical Executives are providing leadership and challenge to addressing this important issue and it is a personal ambition as Chief Executive that we eradicate these delays as soon as we practically can. I trust that this information reassures you about the Health Board’s plans to improve ambulance handover delays. However, if you require any further information or assurance, please do not hesitate to contact me. Yours sincerely Prif Weithredwr | Chief Executive
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