Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0411, written 4 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jul 2024 |
|---|---|
| Reference | 2024-0411 |
| Deceased | Harry Dunn |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| Category | Road (Highways Safety) related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Midlands Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
Secretary of State for Health and Social Care
1 | CORONER
I am Anne Pember, HM Senior Coroner for Northamptonshire
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 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN
aged 19. The investigation concluded at the end of the inquest on 13 June 2024. The
conclusion of the inquest was:
Road Traffic Collision
4 | CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows: -
On 27 August 2019 at about 2030 hours there was a head on collision between a car driven
by Es employee of the US Government who had not long been in the UK
and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr
Harry Dunn. The cause of the collision was that on exiting RAF Croughton
inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350
meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on
the correct side of the road travelling out of the village of Croughton.
Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which
were open in nature and a fracture to his pelvis with the concomitant severe internal blood
loss commonly associated with such serious injuries.
He was attended to by an advanced medical team including a Consultant Anaesthetist and
Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.
5 | CORONER’S CONCERNS
During the course of the investigation my inquiries 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:
(brief summary of matters of concern)
(1) When the 999 call was made shortly following the accident no resources were
available within either the operating area of the relevant ambulance trust, East
Midlands Ambulance Service Trust ("EMAS“) or within the neighbouring South Central
Regulation 28 — After Inquest
Document Template Updated 30/07/2021
Ambulance Service Trust. The only available emergency medical resource was that
run by the Air Ambulance Service Charity which was an advanced medical team
based out of Coventry Airport, some c.30 miles away with an estimated arrival time
of 57 minutes.
(2) The Inquest heard that EMAS was unabie to meet mean response standards at the
time of the 999 call. They had entered a sustained period where demand was
outstripping the resources they had available. This was worsened by the fact that
what resources they did have were being delayed at hospitals due to lengthy hospital
handovers at the Accident and Emergency departments.
(3) Although EMAS reported a slight improvement in the issue of resourcing following the
adoption of the newer NHS Pathways triage process the delay in paramedics
attending Category 2 calls has not been resolved to within target ranges. This is
because EMAS’s resources cannot be fully utilised as a result of the delays in
ambulances clearing Accident and Emergency departments.
(4) Iam concerned that these continuing delays for ambulances at hospital handovers
reflects a risk of deaths into the future.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by August 29, 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I
have also sent a copy of this report to West Northamptonshire Council, Northamptonshire
Police, to the Chief Executive of East Midlands Ambulance Service and the solicitors on behalf
of
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.
I may also send a copy of your response to any person who I believe may find it useful or of
interest.
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.
Dated: 4* July 2024 |
Mrs Anne Pember A Po os Peeios/
His Majesty's Senior Coroner for the County of Northamptonshire
Regulation 28 — After Inquest
Document Template Updated 30/07/2021
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.
a Ct De partment Minister of State for Health of Health & 39 Victor Street Social Care SW1H OEU Our ref: as Anne Pember His Majesty's Senior Coroner The Guildhall St Giles' Square Northampton NN1 1DE Northamptonshire 224 August 2024 Dear Ms Pember, Thank you for your two reports of 4 July regarding the death of Harry Peter Dunn. | am replying as Minister with responsibility for urgent and emergency care. Firstly, | would like to offer my sincere condolences to Mr Dunn’s 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. | am grateful for you bringing these matters to my attention. Your reports raise concerns with East Midlands Ambulance Service NHS Trust’s (EMAS) response times, and paramedic access to analgesics. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE) and the Medicines and Healthcare products Regulatory Agency (MHRA). | understand MHRA will write to you separately regarding the report for which they are a direct recipient. In relation to ambulance service performance, the Government accepts that response times have been below the high standards that patients should expect in recent years. The NHS has been broken and it will take time to fix. However, we are determined to do so and have committed to returning urgent and emergency care waiting times to the safe operational waiting time standards set out in the NHS constitution. For Category 2 incidents, this would mean an average response time of 18 minutes compared with current NHS performance (July 2024) of 33 minutes 25 seconds. As a first step, the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces. The investigation’s findings will feed into the Government's work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future. In the shorter-term, a range of action is being taken by the NHS this year to improve performance including maintaining the increase in ambulance capacity (hours on the road) delivered in 2023/24, where NHSE reported a circa 6% increase year-on-year for December 2023. There is a focus on reducing ambulance handover delays to support patient flow and on increasing direct referrals into community services to reduce conveyance rates to acute hospitals. NHSE has advised my officials that the regional team for the Midlands will continue to have regular review meetings with EMAS including on the support needed to improve response times performance and the quality of care for patients. It is recognised that operational productivity has fallen since the pandemic, and while there was improvement during 2023/24, further improvement is required. The NHS’s operational target for 2024-25 is for Category 2 response times to improve to an average of 30 minutes across the year. Regarding your concerns on paramedic access to nasal analgesics, as of 31 December 2023, paramedic independent prescribers who are registered with the Health and Care Professions Council can prescribe and administer the following five controlled drugs: e Morphine sulphate by oral administration or by injection Diazepam by oral administration or by injection Midazolam by oromucosal administration or by injection Lorazepam by injection Codeine phosphate by oral administration Paramedics without an independent prescribing qualification can also administer a range of medicines on their own initiative via exemptions under the Human Medicines Regulations 2012. Please be assured that we will take account of your concerns when agreeing the next steps in our joint work programme with NHSE regarding expanding supply, administration and prescribing of medicines responsibilities for regulated healthcare professionals. Thank you once again for bringing these concerns to my attention. * _ po
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