Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0657, written 2 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2024 |
|---|---|
| Reference | 2024-0657 |
| Deceased | Keith Foord |
| Coroner | Rachel Redman |
| Coroner area | East Sussex |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England 1 CORONER I am Rachel Redman, Assistant Coroner for the coroner area of East Sussex. 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 09 May 2022 I commenced an investigation into the death of Keith David FOORD aged 76. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was that: Dr K D Foord sustained a Type A Aortic dissection on 2.5.22. His symptoms caused him to request an ambulance to go to the A and E Department at Conquest Hospital, Hastings arriving at 9.30am that day. An accurate diagnosis was made at 12 midday and arrangements were made with Royal Sussex County Hospital, Brighton to transfer his care to their cardiac surgery unit. A Category 2 ambulance was called for which took 1hr 19 minutes to arrive, 1 hr later than the 18 minute response time required by a Category 2 case. Dr Foord was taken to theatre and underwent a lengthy operation, but the right coronary artery had completely detached from the aorta by the time surgery began which disaffected significantly his chances of survival. Dr Foord died at 7.30am on 3.5.22, the cause of death being:- 1a) Acute type A Aortic Dissection (Emergency Aortic Repair 2/5/22). 4 CIRCUMSTANCES OF THE DEATH Dr Foord died as a result of an Acute type A Aortic Dissection in spite of undergoing emergency repair on 2nd May 2022. He had presented to A and E at The Conquest Hospital where the correct diagnosis was made in a timely manner. He required an ambulance to take him to Royal Sussex County Hospital, Brighton where the regional cardiac surgery is undertaken. His case was categorised as 2 for response time for the ambulance service when all of the clinical, paramedic and expert witnesses whose evidence I heard at the inquest advised that it should be correctly categorised as 1 given the critical requirement for emergency surgery. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: During the course of the investigation my inquiries revealed matters giving rise to concern, namely that for aortic dissection requiring emergency surgery and inter facility transfer, the category of this type of case for transfer should be raised to category 1. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 27, 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Dr Foord’s family East Sussex Healthcare NHS Trust South East Coast Ambulance Service I have also sent it to Royal Sussex County Hospital Cardiac Surgery Directorate 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. 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. 9 Dated: 02/12/2024 Rachel REDMAN Assistant Coroner for East Sussex 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.
Ms Rachel Redman
HM Assistant Coroner
East Sussex Coroner’s Office
Unit 56
Innovation Centre
Highfield Drive
St Leonards on Sea
East Sussex
TN38 9UH
National Medical Director for
Secondary Care and Quality
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
17 February 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Keith David Foord who
died on 3 May 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2
December 2024 concerning the death of Keith David Foord on 3 May 2022. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Keith’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Keith’s care have
been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Keith’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raises a concern in relation to the categorisation of ambulances in cases
of aortic dissection requiring emergency surgery and inter-facility transfer, and the fact
that Keith was categorised as Category 2 rather than Category 1 when there was a
critical requirement for emergency surgery. NHS England has separately heard from
Keith’s family in respect of the expert evidence from Mr Michael Sabetai on this issue.
I also note the family’s concerns around the length of time it took for the Category 2
ambulance to arrive on 2 May 2022, including the impact of the delayed inter-facility
transfer on Keith’s chances of survival. I am grateful to the family for taking the time to
write to NHS England directly, and I hope that this response addresses all of the points
they have raised.
NHS England published the National framework for inter-facility transfers in July 2019,
which was last updated on 12 December 2024. The framework is intended for patients
who require transfer by ambulance between facilities due to an increase in either their
medical or nursing care needs.
Patients who have immediate life-threatening injuries or illnesses should be
transferred within a set timeframe mapped to Ambulance Response Programme
(ARP) categories. Similarly, patients with serious or urgent healthcare needs should
be transferred in an appropriately commissioned timeframe.
Inter-facility transfers (IFT) Level 1 (IFT1) Category 1
As stated in the National framework, this level of response should be reserved for
those exceptional circumstances when a facility is unable to provide immediate life-
saving clinical intervention such as resuscitation or, in the case of a declared obstetric
emergency, when a facility requires the clinical assistance of the ambulance trust in
addition to a transporting resource.
These requests should be processed through the trust’s 999 triage tool and only those
that are deemed a Category 1 under that assessment should receive a Category 1
response. Examples would include cardiac arrest, anaphylaxis, birth units requiring
immediate assistance or acute severe life-threatening asthma in an urgent care facility.
IFT Level 2 (IFT2) Category 2
This level of response is based on the clinical condition of the patient and the need, or
a high likelihood of the need, for further treatment and management at the destination
facility rather than the patient’s diagnosis.
Immediate life, limb or sight threatening situations that require immediate management
in another healthcare facility should receive this level of response. Other examples
include patients going directly to theatre for immediate primary percutaneous coronary
intervention (PPCI), stroke thrombolysis, or surgery for ruptured aortic aneurysm.
These IFT Level 2 patients are mapped to a Category 2 response.
Both IFT Level 1 and Level 2 incidents are confirmed emergencies which require life-
saving intervention and should be responded to as time critical emergencies and
immediately allocated the nearest appropriate response. An IFT Level 1 or Level 2
incident must be treated exactly the same as any other Category 1 or Category 2
community ambulance response, and must not be deprioritised simply because the
patients are in an existing hospital or care setting. The framework does allow for
clinical discretion to be applied in some cases where the patient’s condition
does not precisely meet the definition, but additional considerations are involved.
If an ambulance is not immediately available for dispatch to an IFT Level 1 or 2
call, this incident should be escalated within the ambulance operations centre to
ensure an appropriate response and maintenance of clinical oversight whilst waiting
for dispatch. This means that a clinician requesting transfer for a patient with an aortic
aneurysm can advise the clinician in the 999 operations centre of the plan on arrival
at the receiving hospital, so that an appropriate clinical priority can be agreed.
In December 2024, NHS England amended the National framework to advise that
requests for an inter-facility transfer for a patient, where the stroke / cardiology team
are accepting patients for immediate intervention (i.e. mechanical thrombectomy or
primary percutaneous coronary intervention (PPCI)), should be clinically navigated
and prioritised for a Category 2 dispatch.
Ambulance response times
NHS England recognises the significant pressures on all NHS services, including
ambulances, and has been prioritising improvements to Category 2 response times
and urgent and emergency care services. NHS England’s ambitions for 2024/25 have
been set out in the NHS priorities and operational planning guidance, which includes
improving Category 2 ambulance response times relative to 2023/24, to an average
of 30 minutes across 2024/25.
NHS England has also recognised the need to increase ambulance capacity through
growing the workforce, improving flow through hospitals and reducing handover
delays, speeding up discharges from hospital and expanding new services in the
community; all of which support improved patient flow and ambulance response
times. The NHS is also working more closely with local authorities to improve the
timely discharge of patients and has developed discharge metrics to monitor
performance improvements.
Improvements to ambulance response times are also being enabled by addressing
excessive handover delays. Rapid handovers are essential to ensure that patients
reach definitive care promptly, which includes both those waiting to receive care in the
Emergency Department, and those waiting in the community. NHS England continues
to work with trusts and services with significant handover challenges at the ‘front end’,
alongside recognising the importance of reducing length of stay and timely discharge
to maintain adequate patient flow and allow new patients to be handed over more
promptly to Emergency Departments (or, in Keith’s case, to be transferred from the
Emergency Department in one hospital and handed over to the cardiac team in
another hospital).
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Keith,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Clinical Director for Elective Care
National Medical Director for Secondary Care and Quality
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