Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0492, written 16 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2024 |
|---|---|
| Reference | 2024-0492 |
| Deceased | Philip Ross |
| Coroner | Susan Ridge |
| Coroner area | Surrey |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | South East Coast 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Philip Gordon Ross A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Chief Executive South East Coast Ambulance Service NHS Foundation Trust Nexus House 4 Gatwick Road Crawley RH10 9BG 2 CORONER Ms Susan Ridge, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST An inquest into Mr Ross’s death was opened on 4 January 2024. The inquest was resumed and concluded on 23 August 2024. The medical cause of Mr Ross’s death was: 1a. Multiple Organ Failure Ib. Bronchopneumonia and Rhabdomyolysis Ic. Fall 2. Myocardial Fibrosis With respect to where, when and how Mr Ross came by his death it was recorded at Box 3 of the Record of Inquest as follows: Philip Gordon Ross had a fall at his home injuring his shoulder sometime before 2325 hours on the evening of 3 December 2023. He was unable to move until extracted by paramedics and he was taken by ambulance to the Royal Surrey County Hospital Guildford and admitted to the Emergency Department at around 0416 hours. Within a day or so of admission he was found to have acute kidney injury secondary to rhabdomyolysis, symptoms of myocardial injury and pneumonia. He did not respond to treatment and his condition continued to deteriorate. Mr Ross died on 19 December 2023 at the Royal Surrey County Hospital of multiple organ failure caused by rhabdomyolysis and bronchopneumonia precipitated by his fall on a background of myocardial fibrosis. The inquest concluded with a short form conclusion of ‘Accident’: 5 CIRCUMSTANCES OF THE DEATH On 3 December 2023, Mr Ross suffered a fall at his home and was unable to move. His wife called for an ambulance at 23:25 hours. At that point his case was categorised by South East Coast Ambulance Service (SECAMB) as a Category 3 case. Category 3 calls have a response time of 120 minutes. Mrs Ross then made a number of increasingly anxious calls to the ambulance service about the need to help her husband, these included a call at 00:48 hours. It was accepted in evidence that Mr Ross should have been re-triaged at this point as his condition had deteriorated. The court heard he was not triaged again until 01:42 hours, when a nurse clinical supervisor upgraded the call to Category 2 with a response time of 18 minutes. The ambulance did not arrive until around 02:30 hours. SECAMB have adopted the NHS England protocol for validating Category 3 and Category 4 ambulance calls. They therefore aim to validate such cases within 90 minutes of the call. That was not achieved in Mr Ross’s case. The evidence showed that no form of clinical validation of the calls took place until approximately 2 hours and 20 minutes after the initial call. The court heard that the delay in an ambulance attending Mr Ross was because there had been a high demand for ambulance/paramedic assistance over that period. And that no clinical validation of the calls took place until well over 2 hours from the initial call because of a lack of available clinical staff or clinical hours to deal with the level of surge in calls that night. 6 CORONER’S CONCERNS The MATTER OF CONCERN is: Under the Ambulance Response Programme, Category 3 and 4 cases have response times of 120 and 180 minutes respectively. SECAMB aim to validate these calls within 90 minutes to ensure that patients receive the most appropriate care at the right time. However, SECAMB have not produced evidence that their timeline for clinical validation is being met and it was not met in this case. Categories 3 and 4 are deemed less serious cases and therefore have extended response times for ambulance attendance, which can become further extended at times of high demand. Because of these potentially long response times, timely clinical validation is important to ensure correct categorisation and/or identify a deteriorating situation. The coroner is concerned that late re-triage or clinical validation of Category 3 and 4 calls is placing patients at risk of early death. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mr Ross’s family 10 Signed: Susan Ridge H.M Assistant Coroner for Surrey Dated this 16th day of September 2024
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.
Ms Susan Ridge H.M Assistant Coroner for Surrey 06 November 2024 Dear Madam Philip Gordon Ross deceased I write in response to the Regulation 28 Prevention of Future Deaths report issued on 16 September 2024 following the inquest into the sad death of Mr Ross. I was very sorry to learn of the death of Mr Ross and I would like to convey my heartfelt condolences to his family and friends. I note your concern is that “SECAMB have not produced evidence that their timeline for clinical validation [of 90 minutes] is being met and it was not met in this case”, and that. “late re-triage or clinical validation of Category 3 and 4 calls is placing patients at risk of early death.” For the 12-month period from November 2023 to October 2024 South East Coast Ambulance Service (The Trust) clinically validated 115,688 Category 3 & Category 4 incidents, the mean time to reach the validation outcome over this period was 74 minutes, with the mode time to reach validation outcome being 30 minutes. The number of validations being undertaken has steadily increased with demand over the last year with 9,150 incidents being clinically validated per month in November 2023 rising to 11,148 incidents per month being clinically validated in October 2024. Despite this rise in demand and number of incidents being validated the mean time in October 2024 to reach validation outcome was 75 minutes, with the mode time to reach validation outcome remaining at 30 minutes. We acknowledge however that our aim to validate calls within 90 minutes is not being achieved for all patients and over the last 12 months we have reviewed several of our processes and the operational model that positively impacts on better performance in this area. Since February 2024 we have further worked collaboratively to optimise the use of Urgent Community Response (UCR) Teams across the region. UCR teams are NHS rapid response community-based teams comprising of specialist health care professionals who are able to respond to patients within 2 hours of referral and implement interventions or treatments within the patient’s home, such as managing patients who have fallen. We have implemented an innovative ‘portal’ that these teams' access and are able to ‘pull’ patients from the Category 3 & Category 4 awaiting validation queue, responding directly to a range of appropriate patients themselves who would otherwise be anticipating an ambulance service response. This has resulted in timelier clinically appropriate responses for over 1,160 patients to date who otherwise would have been waiting for clinical validation. In July 2024 we introduced automated welfare SMS texting for patients awaiting a response from our service, this was following a Quality Improvement project which identified that patients benefited from being kept informed, reminded to contact us if they had concerns regarding deterioration and also giving them the ability to reply to the SMS message to cancel a response from our service if it was no longer required. This has released 23 days of call handling time since go live of this automated innovation which previously was required in the manual management of such calls, allowing call handling and clinical teams to focus and prioritise other patients waiting, and reduce callback delay. We have changed our operating model with regards Category 3 & Category 4 validation with the aim of evaluating its effectiveness over the coming months, this change of working introduced in October 2024 has seen the rollout of Urgent Care Navigation Hubs (UCNHs) based across the region, with a local focus alongside community teams from within the geography to review and undertake clinical assessments of patients awaiting a response, local oversight with “Zoning” of individual areas has given early indication of potentially identifying incidents that would benefit from earlier clinical intervention, particularly from a multi-disciplinary approach to avoid further deterioration. UCNHs continue to receive full oversight from our centralised clinical assessment team based within our control rooms, however the “Zoning” of geographical areas for all clinicians working on Category 3 & Category 4 validations also benefits these teams with replication of the potential to identify and prioritise patients that are deteriorating on a localised basis with specific clinicians assigned to individual areas of the Trust’s footprint. We are currently undertaking a review of our ‘failed callback process’, ensuring we learn from other ambulance trusts, to make the process of what we do when a patient does not answer the phone on our call back, safe and efficient. The aim is to minimise the patient’s waiting time for an ambulance response by reducing the time between the first attempt to call back a patient and the last attempt when a decision is made to dispatch an ambulance resource In line with continuing high levels of anticipated demand as we approach winter an extensive recruitment campaign is under way for substantive staff, paramedics and experienced agency nurses to work in our control rooms focusing on the clinical validation of 999 calls. We continue to operate within a challenged healthcare system with our 999 & 111 services often facing surges in activity as a barometer of pressures being experienced in the wider NHS. We recognise at times because of this we will have patients that are waiting longer for a response and have implemented a harm review process into those patients who are experiencing the longest daily waits for Category 3 & 4 validation. This information is used to identify learning and ensure our operational processes are continually reviewed and improved. Our new Trust Strategy was formally launched in August 2024 focuses on our commitment to provide patient care differently moving forwards, with an improved and faster response to our emergency patients currently falling in C1 and C2 categorisation, and improved technology and skills working with system partners to better meet the needs of those patients requiring urgent care. There is a sharper focus on increasing the use of virtual consultation and navigation to rapidly connect the right response and right service to each need identified for these patients. Some of the key deliverables such as Urgent Care Navigation Hubs, again focused on multi-disciplinary local teams focusing on C3 and C4 patients to provide timelier and more appropriate responses, changes within our operating model and the rollout of technologies such as the UCR portal as described within this response are all aligned with the Trust’s strategic direction. I hope this response clearly sets out our commitment to meet the needs of all patients requiring an urgent response from us and from the wider system. If I can be of any further assistance, please do not hesitate to contact me. Yours sincerely Executive Director of Quality and Nursing/Chief Nurse on behalf of Chief Executive Officer South East Coast Ambulance Service NHS Foundation Trust
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