Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0697, written 19 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 | 19 Dec 2024 |
|---|---|
| Reference | 2024-0697 |
| Deceased | Andrew Lewis |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Secretary of State for Health and Social Care. 2 Chief Executive, NHS England. 1 CORONER I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire The family asked me to refer to the deceased as Andrew. This report reflects that request. 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. It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature and engages no civil or criminal right or obligation on the part of the recipient, other than the obligation to respond to the report in writing within 56 days. 3 INVESTIGATION On 22nd of May 2024 I opened an inquest into the death of Andrew Michael Lewis. The inquest was conducted on 6th of December 2024. The cause of death was: 1a) Acute on Chronic Gastrointestinal Haemorrhage 1b) Bleeding Oesophageal Varices 1c) Alcoholic Liver Cirrhosis 2) Low volume Subdural Haemorrhage The conclusion of the inquest was: Regulation 28 – Before Inquest Document Template Updated 30/07/2020 Alcohol-related, contributed to by head injury. 4 CIRCUMSTANCES OF THE DEATH Andrew Lewis was a 55 year old man who died at home on the 7th of May 2024. He called 111 at 13:42 on 7th of May 2024, reporting weakness in his legs and an earlier fall. The key times are: 13:42 15:17 23:45 Called 111, categorised as Category 3 (ie response time within 120 minutes for 90% of calls). This decision required confirmation by a clinician within South Central Ambulance Service (‘SCAS’), as the original call was to 111. SCAS categorised the call as Category 3. The 120 minute ‘clock’ began to run at this point. An ambulance should therefore have been in attendance by 17:17. Ambulance arrived. Andrew was deceased. This ambulance arrived because family and police had attended the property, broken in and found him unresponsive – the call was then categorised as Category 1 (the most urgent category). I accepted at inquest that the reason for this chronology was that there was simply no ambulance to send earlier. 5 CORONER’S CONCERNS During the course of the investigation my enquiries 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: Regulation 28 – Before Inquest Document Template Updated 30/07/2020 Facts of this case An ambulance resource arrived around 10 hours from Andrew’s first call (to 111 services), and 8 ½ hours after the ambulance service categorised this as a call requiring attendance within 2 hours. South Central Ambulance Service generally The NHS has a framework called OPEL (Operational Pressures Escalation Level), designed to manage capacity at times of excess demand. SCAS’ version of this is called REAP (Resource Escalation Action Plan). The levels are: REAP level 1 – Steady state. REAP level 2 – Moderate pressure. REAP level 3 – Major pressure. REAP level 4 – Extreme pressure. There are also categories for critical incidents and major incidents. I obtained information from South Central Ambulance Service about their escalation levels in the last 2 years. The specific data can be provided, but the headlines (for the period 3rd of August 2022 to 9th of October 2024) are: SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024. The lowest escalation level that this ambulance service has been at in this period is REAP 2. They have never been at steady state (REAP 1) during this period. I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day. The national picture 1. In the period July 2013 to 24th November 2024, 217 Prevention of Future Deaths Reports (‘PFDs’) were written to ambulance trusts. It is fair to say that Regulation 28 – Before Inquest Document Template Updated 30/07/2020 not all of these will relate to delay, but a significant number of them do. 2. There appears to be no oversight of this issue, and a number of ambulance 3. trusts have not responded to these reports at all. I have attached an article published by the Preventable Deaths Tracker in November 2024, which provides further information regarding ambulance PFD reports. 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 February 13th, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons or organisations who may find it useful or of interest: 1. Andrew’s family. 2. South Central Ambulance Service NHS Foundation Trust. 3. Association of Ambulance Service Chief Executives. For the avoidance of doubt, a response is only requested from the two recipients referred to at the top of this report. I am also under a duty to send the Chief Coroner a copy of your responses. 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: 19/12/2024 Regulation 28 – Before Inquest Document Template Updated 30/07/2020 HEIDI J CONNOR Senior Coroner for Berkshire for Berkshire Regulation 28 – Before Inquest Document Template Updated 30/07/2020
12/16/24, 4:45 PM Deaths in the NHS: Ambulance Trusts Deaths in the NHS: Ambulance Trusts A matter of life or death NOV 28, 2024 ∙ PAID 6 4 Share Coroners have been sending reports to organisations to take action to prevent futu deaths for over 11 years. However, no one is responsible for understanding who receives these reports, whether they respond, and if action is taken. The Preventab Deaths Tracker is changing this: the only platform that provides real-time statistic To highlight what the Preventable Deaths Tracker’s databases can do, I’m launchi new series to share speci c analyses on the organisations receiving coroner report Today, I’m starting with Ambulance Trusts - the service we rely on in emergencie o en matters of life or death. 217 coronersʼ reports There are 11 Ambulance Trusts in England and Wales. Collectively, coroners sent reports to Ambulance Trusts between July 2013 and 24 November 2024. One- h of reports were sent to the Welsh Ambulance Services, and one-tenth (12%) were s to the London Ambulance Service. https://preventabledeaths.substack.com/p/deaths-in-the-nhs-ambulance-trusts 1/5 12/16/24, 4:45 PM Deaths in the NHS: Ambulance Trusts Every organisation that receives a coroners’ report should respond to all (100%) rep by law. The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published. The London Ambulance Service has the worst response rate, with only one-third (35%) of repor with published responses. Support the Preventable Deaths Tracker by becoming a subscriber. Trends over time Ambulance Trusts received the most (16%) reports in 2019, with trends dropping during the COVID-19 pandemic. https://preventabledeaths.substack.com/p/deaths-in-the-nhs-ambulance-trusts 2/5 12/16/24, 4:45 PM Deaths in the NHS: Ambulance Trusts Do Ambulance Trusts track their reports? Organisations don’t publish statistics on how many reports they receive from coro and what actions they take to prevent future deaths. Sharing this information wou build a national learning culture where similar organisations could adopt similar actions. To understand whether Ambulance Trusts were capturing (and hopefully using) th information, I asked them. The majority (54%) of Ambulance Trusts initially refuse share any information, citing that it was already available via the judiciary website as I’ve mentioned before, the entire “system” relies on email exchanges, so not all written reports get published. A er explaining this, one-third (36%) of Ambulance Trusts continued to refuse to share any information, including: 1. London Ambulance Service NHS Trust, 2. East Midlands Ambulance Service NHS Trust, 3. East of England Ambulance Service NHS Trust, and 4. Yorkshire Ambulance Service NHS Trust. https://preventabledeaths.substack.com/p/deaths-in-the-nhs-ambulance-trusts 3/5 12/16/24, 4:45 PM Deaths in the NHS: Ambulance Trusts The remaining Ambulance Trusts shared all or some of their data. When comparin the information shared with the Judiciary website, three Ambulance Trusts underreported (i.e. the Trusts are missing reports), and two Ambulance Trusts repo more reports (i.e. the judiciary website is missing reports). It’s a mess. The Welsh Ambulance Services University NHS Trust reported that since 2022, th using a national database 'Once for Wales' Datix Cymru system to record its inque management. So, it’s great to hear work is being done to improve data capture, but English Ambulance Trusts (and the other 2,000+ organisations that receive corone reports) now need to follow. The Verdict The lack of any “system” to track and use coroners’ reports is a missed opportunity Local approaches to improve data capture are a positive start, but a national appro is needed. Until then, the Preventable Deaths Tracker will keep tracking. 6 Likes · 4 Restacks Previous Next Discussion about this post Comments Restacks Write a comment... https://preventabledeaths.substack.com/p/deaths-in-the-nhs-ambulance-trusts 4/5 12/16/24, 4:45 PM Deaths in the NHS: Ambulance Trusts © 2024 ∙ Privacy ∙ Terms ∙ Collection notice Substack is the home for great culture https://preventabledeaths.substack.com/p/deaths-in-the-nhs-ambulance-trusts 5/5
2 responses 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 12 February 2024 Our ref: HM Coroner Heidi Connor Coroner’s Office Reading Town Hall Blagrave Street Reading RG1 1QH By email: Dear Ms Connor, Thank you for the Regulation 28 report of 19 December 2024, sent to the Secretary of State for Health and Social Care, about the death of Andrew Michael Lewis. 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 Lewis’ death and I offer my sincere condolences to his family and loved ones. The information your report provides are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over long ambulance response times, the ongoing operational pressures experienced by South Central Ambulance Service, ambulance handover delays at hospitals, the oversight of Prevention of Future Death reports and issues with ambulance trusts responding to reports. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that NHS England, as the appropriate body, will be responding to your concern raised on the response to prevention of future death reports sent to individual ambulance trusts. The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years. I also recognise that the number of reports being raised by coroners in relation to ambulance response times is concerning. I would like to assure you that the Government is committed to getting ambulance response times back to the NHS Constitutional standards. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however we must be clear that there are no quick fixes. To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010. We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for- change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future. On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays. In Spring 2025, to accompany the additional investment in the NHS, the Government will publish its 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Ms Heidi J Connor
Senior Coroner
Berkshire Coroner’s Office
Reading Town Hall
Blagrave Street
Reading
RG1 1QH
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 February 2025
Re: Regulation 28 Report to Prevent Future Deaths – Andrew Michael Lewis
who died on 7 May 2024
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19
December 2024 concerning the death of Andrew Michael Lewis on 7 May 2024. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Andrew’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Andrew’s
care have been listened to and reflected upon.
Your Report raised concerns over the pressures being placed on ambulance trusts,
and the delays to response times this can cause. You raised concerns regarding South
Central Ambulance Service (SCAS) specifically, but also the national picture.
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 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.
NHS England’s ambitions for 2024/25 have been set out in the NHS priorities and
operational planning guidance. These include:
•
•
improving Category 2 ambulance response times relative to 2023/24, to an
average of 30 minutes across 2024/25; and
improving A&E performance with 78% of patients being admitted, transferred,
or discharged within 4 hours by March 2025.
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 (ED), 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 EDs.
Your Report also raised that there appears to be no oversight of Prevention of Future
Death (PFD) Reports written to ambulance trusts, and a significant number of these
Reports relate to ambulance delays. PFD Reports sent to ambulance services are
reviewed by the Association of Ambulance Chief Executives (AACE) National
Ambulance Services Medical Directors’ Group (NASMeD) and the AACE Quality
Governance Group to capture themes and learning. I also wish to provide assurance
that all PFDs regarding ambulance services that are sent to NHS England are
reviewed by our National Ambulance Team, as well as being discussed at our
Regulation 28 Working Group (see penultimate paragraph below). NHS England is
unable to provide comment on individual trusts not responding to PFD Reports.
Regarding SCAS specifically, they have advised us that PFD Reports addressed to
them are shared with all SCAS clinical leads and executives for awareness. On review,
if it is felt that changes are required then these are discussed with the relevant service
line director and governance leads who will determine the best way to mitigate or
eliminate the concern raised, with proposed responses being reviewed by the CEO.
They are required to share all PFD Reports received with the Care Quality
Commission (CQC) and their commissioning Integrated Care Boards. As well as
sharing PFD Reports and responses with AACE, they will also share them with
NASMeD.
SCAS also advise that they review other ambulance service PFD Reports through
their Learning from Deaths (LFD) forum, which is chaired by an Assistant Medical
Director. The forum will discuss whether concerns addressed to other ambulance
services are also relevant to SCAS and whether additional action is required.
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
Andrew, 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,
Professor Sir Stephen Powis
National Medical Director
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