Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0569, written 21 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2024 |
|---|---|
| Reference | 2024-0569 |
| Deceased | Henry Willems |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | Worcestershire Acute Hospitals NHS Trust · West Midlands Ambulance Service University 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Social Care, 39 Victoria Street, London SW1H 0EU. , Secretary of State of Health and 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 11 March 2024 I commenced an investigation and opened an inquest into the death of Henry Michael Patrick WILLEMS. The investigation concluded at the end of the inquest on 21 October 2024 The conclusion of the inquest was that Mr. Willems “died from natural causes, to which the lack of a timely ambulance response contributed.” 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Willems come by his death?”, I recorded as follows: “In the early hours of 12.10.23 Mr. Willems, who had been unwell with gastritis over the preceding 48 hours, collapsed at his home in Malvern. His family called the emergency services, and paramedics attended him at home, but he was confirmed deceased a short time later. Paramedics had been unable to attend Mr. Willems’ address within the mean target response time for a Category 2 case because ambulances were experiencing significant delays in handing their patients over to staff at hospital emergency departments across the region. Had that mean target response time been met, it is likely that Mr. Willems would have survived.” A post mortem examination confirmed the medical cause of death for Mr. Willems was: 1a ischaemic heart disease. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1) In the course of the inquest, I heard evidence from the Patient Safety Learning Lead for West Midlands Ambulance Service University NHS Foundation Trust ( WMAS ), who told me: 1 (a) Mr. Willems’ case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90th percentile response time is 40 minutes; (b) Those response times were not met, as Mr. Willems was not reached by paramedics until some 2 hours 18 minutes after the “clock start” time for his case; (c) The Trust was unable to meet the applicable mean and 90th percentile response times, because at the time of these events, it was operating at Emergency and Urgent Surge Level 4 ( the highest level which can be applied ). The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes. 2) I heard expert evidence that Mr. Willems would probably have survived this episode, and would not have died when he did, had paramedics been able to attend his home address within the applicable 18 minute mean response time. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Secretary of State for Health and Social Care, 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 16th December 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: (a) (b) West Midlands Ambulance Service University NHS Foundation Trust; (c) Worcestershire Acute Hospitals NHS Trust. , Mr. Willems’ daughter; 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 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 21 October 2024 David REID HM Senior Coroner for Worcestershire 2
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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 20 December 2024 Our ref: HM Senior Coroner David Reid, Worcestershire Coroner’s Court, The Civic, Martins Way, Stourport-on-Severn, Worcestershire DY13 8UN By email: Dear Mr Reid, Thank you for the Regulation 28 report of 21 October 2024 sent to the Secretary of State for Health and Social Care about the death of Henry Willems. I am replying as the Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Willems’ death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns over delayed ambulance response times at West Midlands Ambulance Service University NHS Foundation Trust (WMAS), and handover delays between WMAS and the Worcestershire Acute Hospitals NHS Trust. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that WMAS is implementing urgent changes to improve ambulance response times. I am advised WMAS is increasing the number of operational staff who will be actively responding to patients and the number of ambulances on the road to reduce service pressures. WMAS is also increasing the number of paramedics and nurses working in the control rooms to increase ‘Hear and Treat’ rates and, where appropriate, refer the patient onto a range of other NHS services such as urgent care, occupational health teams or arrange for the patient to go directly to a specialist ward in hospital. This work helps patients avoid unnecessary hospital visits and receive more timely care in the community, which in turn relieves pressure on the emergency departments. WMAS has also established an Operational Oversight Delivery Programme Board, which is chaired by their CEO, that aims to provide comprehensive oversight of operational performance, with a specific focus on improving Category 2 call response times. Regarding ambulance handover times, WMAS uses a dynamic conveyancing process to make real-time decisions on where to take patients based on the current demands within the region. The aim is to direct patients to hospitals with lower pressure to prevent overloading any single site and increasing handover delays. WMAS has been actively collaborating with NHS England and the six Integrated Care Boards in the West Midlands to reduce handover times at hospitals. At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and 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 short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs. This government is also working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges, increasing urgent and emergency care capacity. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
See every Prevention of Future Deaths report matching Worcestershire Acute Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.