Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0063, written 30 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2025 |
|---|---|
| Reference | 2025-0063 |
| Deceased | Graham Whiteley |
| Coroner | Vanessa McKinlay |
| Coroner area | Somerset |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | South Western 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.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: South Western Ambulance Service NHS Foundation Trust CORONER I am Vanessa McKinlay, Assistant Coroner for Somerset 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. INVESTIGATION and INQUEST On 24 June 2024 I commenced an investigation into the death of Graham Whiteley. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was: Accident. CIRCUMSTANCES OF THE DEATH Mr Whiteley suffered from Alzheimer’s disease with a history of seizures and falls. He lived in a care home. On 9 June 2024, Mr Whiteley walked out of the care home alone when the doors were inadvertently and momentarily left unlocked. He was found by a member of the public having fallen at the side of the road and sustained head injuries. Owing to severe pressure on the ambulance service, an ambulance was not dispatched until a decision had already been made for the police to convey Mr Whiteley to Musgrove Park Hospital. On admission to hospital he was diagnosed to have sustained facial fractures and an intracranial bleed. Neurosurgery was not indicated owing to Mr Whiteley’s frail condition and co- morbidities. He developed pneumonia and he died in hospital on 18 June 2024. (Consultant Trauma and Orthopaedic Surgeon) gave the medical cause of death as: 1a Hospital acquired pneumonia 1b Polytrauma secondary to fall 1c Advanced dementia 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: a) The 999 call to the ambulance service was received at 14.24 hours. The Emergency Medical Dispatcher was informed that Mr Whiteley had fallen, had banged his head, was bleeding and was barely conscious. This generated a category 2 response requirement. b) At 15.03 hours there were 107 incidents awaiting allocation across the ambulance Trust area, including 21 in the Bravo patch where Mr Whiteley’s incident occurred. c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary). d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers. This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays. e) An ambulance was allocated to Mr Whitely at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr Whiteley’s ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call. In the event, Avon and Somerset Police conveyed Mr Whiteley to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down. f) g) The evidence given by the ambulance Trust at the inquest was that the delays in allocating ambulances caused by the delays in handing over to acute hospitals is continuing. 6 7 8 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 27 March 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Hummingbird Care Home LLP (Mr Whiteley’s daughter) I have also sent it to the Secretary of State for Health and Social Care, NHS England, ICS, and CQC. 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. She may send a copy of this report to any person who she 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 30 January 2025 Vanessa McKinlay Assistant Coroner for Somerset
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.
Trust Headquarters Abbey Court Eagle Way Exeter Devon EX2 7HY Tel: 01392 261500 Fax: 01392 261510 Website: www.swast.nhs.uk Our ref: 20th March 2025 Vanessa McKinlay Assistant Coroner for Somerset Old Municipal Buildings Corporation Street Taunton TA1 4AQ Dear Ms McKinlay Prevention of future deaths report touching on the death of Mr Graham Whiteley I am writing on behalf of South Western Ambulance Service NHS Foundation Trust (thereafter referred to as the SWAST) in response to a Regulation 28 report to prevent future deaths, issued in relation to death of Mr Graham Whiteley. Our thoughts are with Mr Whiteley’s family, and we send them our sincere condolences. Handover delays at hospital trusts have the biggest impact on SWAST’s ability to respond to patients. This articulated on the SWAST corporate risk register, where a risk related to system activity and flow sits at the highest level, with a risk score of 25. The challenge with impacts of handover delays is that SWAST alone cannot solve it. In August 2023, the Health Services Safety Investigation Body (HSSIB) published a final report ‘Harm caused by delays in transferring patients to the right place of care’. This report strengthens the findings of the SWAST system PSII report that was produced in July 2022, with a review and an addendum added in December 2023. It is recognised that a patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment. At SWAST we are working to combat and reduce handover delays. This is a key priority to improve access to our services and to reduce harm to patients waiting in the community for an ambulance response. To address handover delays, a Standard Operating Procedure (SOP) was introduced in late 2021. This has since been reviewed and updated, with a reassessment against locally agreed standards conducted in December 2023 and January 2024. The SOP facilitates the effective management of delays by employing four handover escalation levels. Local teams have collaborated with each hospital to determine the specific actions to be taken at each level. The triggers for escalation have also been locally established, enabling a more responsive and tailored approach. Additionally, the approach includes a designated area for immediate patient handover in situations where the Trust is unable to respond to a pending local Category 1 call within a reasonable timeframe. SWAST remains committed to collaborating with hospitals to address this issue. In many instances, local operations teams hold daily meetings with their respective Emergency Departments. Resolving delays has been identified as a key priority by the regional NHS England (NHSE) team, and SWAST actively participated in the NHSE Ambulance Handovers task and finish group during the summer of 2024. Additionally, in 2024, a new tier of senior county-level meetings was established, bringing together hospitals, commissioners, NHSE, and SWAST. These meetings have provided SWAST with valuable opportunities to engage in Integrated Care System (ICS) discussions aimed at reducing delays. Building on the aforementioned efforts, several initiatives are being implemented locally and across the South West by SWASFT. These include: • Maintaining a robust ‘Hear and Treat’ approach, with referrals made, where suitable, to alternative services such as NHS 111 or self-care options. • Maximising the use of ‘See and Treat’ to reduce the number of patients transferred to Emergency Departments (ED) unless absolutely necessary. • Providing Hospital Ambulance Liaison Officer (HALO) support at acute hospitals when required to aid patient flow. • Ensuring the Trust’s Operations Delivery Cell minimises resource unavailability as much as possible, increasing the capacity to respond effectively. • Supporting the establishment of the Care Coordination Hub in Somerset, which launched on the 4th November 2024 and co-locating a specialist to further optimise appropriate patient conveyance to ED. • Employing mutual aid solutions, including the use of Private Ambulance Providers, to bolster system support during periods of high demand. These actions reflect a concerted effort to enhance patient care and system efficiency. We have also collaborated with the Somerset system to implement the ‘Timely Handover Process,’ designed to initiate a rapid handover if it has not been completed within 90 minutes of arrival. This process was introduced in the area in November 2024 and following a challenging Christmas period we are now seeing early improvements in handover efficiency. SWAST is dedicated to collaborating with system partners to mitigate handover delays and minimise their impact on our patients. Yours sincerely Chief Executive Officer
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