Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0215, written 2 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2025 |
|---|---|
| Reference | 2025-0215 |
| Deceased | Paul Burke |
| Coroner | Jacques Howell |
| Coroner area | Hertfordshire |
| Category | Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West Hertfordshire Teaching Hospitals NHS 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.
HERTFORDSHIRE CORONER The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 0ES REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health & Social Care 1 CORONER I am Jacques Howell, area coroner, for the coroner area of Hertfordshire 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 1 June 2023 an investigation was commenced into the death of Paul Anthony Burke, aged 41. The investigation concluded at the end of the inquest on 25 April 2025. The conclusion of the inquest was that Mr Burke died as a consequence of Type 2 Respiratory failure, the underlying cause of which was not promptly identified nor treated, thereby contributing to his death. The medical cause of death was found to be: 1a. Type 2 Respiratory Failure 1b. Obesity Hypoventilation Syndrome and Congestive Cardiac Failure 2. Obesity – Grade 3 4 CIRCUMSTANCES OF THE DEATH Mr Burke was a 41-year-old gentleman with a past medical history that included Obesity Hypoventilation Syndrome. On 19 December 2022 he called for an ambulance due to experiencing worsening shortness of breath. The first call to the ambulance service was at 14:07hrs. This generated a category 2 response, requiring an ambulance resource within an average of 18 minutes, with 90% of calls being responded to within 40 minutes. There were further calls to the ambulance service at 14:59hrs, 16:31hrs and 19:09hrs. Throughout this time, the call remained as a category 2 response. No ambulance resource was sent. The final call to the ambulance service was at 20:16hrs, a little over 6 hours from the original call to advise the ambulance service that Mr Burke was being taken to hospital by car by members of his family who had come to assist. Mr Burke arrived at Watford General Hospital at around 20:51hrs. During initial assessment a venous blood gas (VBG) identified that he was experiencing Type 2 Respiratory Failure, Page 1 of 3 and he was therefore transferred to the resuscitation area of the emergency department. Over the following hours he was reviewed by a number of clinicians, all of whom were not aware of the VBG result, and made a diagnosis of fluid overload due to likely heart failure. However, there was no detailed consideration of the underlying cause for Mr Burke’s worsening respiratory function even though his past medical history of obesity hypoventilation syndrome was known. At around 22:30hrs on 20 December 2022, Mr Burke’s condition deteriorated. Arterial blood gas (ABG) testing was undertaken which showed that he was significantly unwell and in Type 2 Respiratory Failure. Consequently, Mr Burke was transferred to the Acute Respiratory Care Unit and was placed on non-invasive ventilation. Sadly, this was not successful and Mr Burke suffered a respiratory collapse and passed away at 07:44hrs on 22 December 2022. On the facts of this particular case, whilst the inability of the ambulance service to send a resource to Mr Burke leading to his delayed presentation to hospital was recognised; the delay was unlikely to have more than minimally contributed to his death. 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 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. – 1. Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care. As set out above, Mr Burke first made a call to the ambulance service at 14:07hrs on 19 December 2022. The call was triaged as requiring a category 2 response, requiring a response within an average of 18 minutes, with 90% of calls being responded to within 40 minutes. I received evidence that category 2 calls are for those whose condition is potentially serious and require rapid assessment, urgent on scene intervention or urgent transport to hospital. By way of example, patients who fall within this category can include those who are unconscious, experiencing chest pain or suffering with stroke symptoms. Despite the urgency with which an ambulance was required for Mr Burke no ambulance resource was available. It was only due to the intervention of his family who came to his aid that he was able to get to hospital – others may not be so fortunate. I heard evidence that on 19 December 2022, the local ambulance service was under extreme pressure. At 14:40hrs on 19 December 2022, the ambulance service had a total of 243 outstanding category 2 calls waiting for an ambulance response. 37 of these were within the Hertfordshire area. This was compounded by the fact that 11 ambulances were delayed at Watford General Hospital, one of which had been waiting to handover their patient for over 5 hours. At 18:01hrs on 19 December 2022, this had grown to 315 outstanding category 2 calls waiting for an ambulance response. 47 of these were within the Hertfordshire area. This was compounded by the fact that 9 ambulances were delayed at Watford General Hospital, waiting to hand over patients. Whilst it is clear that the ambulance service were under extreme pressure on 19 December 2022, on the evidence I heard, this is not an isolated incident. In December of 2022 the average response time for a category 2 ambulance was 61 minutes. In December 2023 the Page 2 of 3 average response time for a category 2 ambulance was 125 minutes. In December 2024 the average response time for a category 2 ambulance was 50 minutes. These times are against a target average response time of 18 minutes. The East of England Ambulance Service (EEAS) has and continues to take action in conjunction with relevant stakeholders to try and minimise these delays. However, there is only so much they and other parties can do. On the evidence that I heard the reasons for ambulance delays appear to be multi-factorial and includes issues throughout the wider health system and are issues not unique to Hertfordshire. In light of the above, I have a concern that is a risk of future deaths occurring due to continuing delays in the provision of pre-hospital emergency care which appear to be multi-factorial in nature. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 27 June 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: 1. The family of Mr Burke 2. The East of England Ambulance Service 3. West Hertfordshire Teaching Hospitals NHS Trust 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. 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. 9 Dated: 2 May 2025 Jacques Howell Area Coroner for Hertfordshire Page 3 of 3
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 27 June 2025 Our ref: HM Coroner Jacques Howell Hertfordshire Coroner Service, The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire AL10 0ES By email: Dear Mr Howell, Thank you for the Regulation 28 report of 2 May sent to the Secretary of State about the death of Paul Anthony Burke. I am replying as the Minister with responsibility for urgent and emergency care. First, I would like to say how saddened I was to read of the circumstances of Mr Burke’s 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. The report raises concerns regarding prolonged ambulance response times, operational pressures faced by the East of England Ambulance Service NHS Trust and ambulance handover delays. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. The Government is clear that patients should expect and receive the highest standard of 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. 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. In Summer 2025, 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. But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: o at least 78% of patients in A&E departments will be seen within 4 hours. A&E 4hour performance in April 2025 was 74.8%; o o reduce ambulance handovers to a minimum of 45 minutes, helping get 550,000 more ambulance back on the road for patients, and reduce category 2 ambulance response time to 30 minutes. Category 2 ambulance performance in April 2025 was averaging c.27 minutes; reduce the number of patients waiting over 12 hours for admission or discharge from an emergency department to less than 10%. 137,207 patients (9.9%) waited over 12 hours from arrival in April 2025; o capital funding of almost £450 million to increase provision of Same Day Emergency Care, Mental Health Crisis Assessment Centres, avoiding unnecessary admissions to hospital and supporting the diagnosis, treatment and discharge on the same day for patients; o support the prevention of people becoming seriously ill from winter respiratory viruses including flu by making it easier to access routine vaccinations for staff and patients. In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays which will improve patient flow through hospitals and reduce ambulance handover delays. These measures mark a fundamental shift in our approach to urgent and emergency care – moving from fragmented efforts to genuine collaboration across the whole system and mean better coordination between NHS trusts and primary care to identify patients most vulnerable during winter. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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