Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2025-0402, written 2 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Aug 2023 |
|---|---|
| Reference | 2025-0402 |
| Deceased | Lee Dryden |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (West District) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | Yorkshire Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health and Social Care 2. NHS England 1 CORONER I am Abigail Combes, assistant coroner, for the coroner area of South Yorkshire (West District) 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 24 January 2022 I commenced an investigation into the death of Lee Dryden born on 1 January 1978. The investigation concluded at the end of the inquest on 6 July 2023. The conclusion of the inquest was:- Narrative Conclusion: On 16th December 2021 Lee Dryden was admitted to hospital and suffered from a cardiac arrest. This resulted in a hypoxic brain injury and his death on 12th January 2022. Prior to the cardiac arrest it was apparent on the 15th that his tracheotomy tube was misplaced however this was not actioned before his cardiac arrest on 16th December 2021. His death was contributed to by neglect. The medical cause of death was: 1a: Hypoxic brain injury 1b: Cardiac arrest 1c: Displacement of tracheotomy tube 2: Laryngeal Squamous Cell Carcinoma 4 CIRCUMSTANCES OF THE DEATH Lee Dryden received a diagnosis of advanced squamous cell carcinoma of the voice box. This was found by chance following a cardiac arrest. As a result of that diagnosis he required a permanent tracheotomy whilst there were investigations undertaken about the best course of treatment for him. Lee was assessed as able to leave hospital with a tracheotomy whilst those investigations were undertaken. He attended an outpatient appointment on 7 December 2021 and there were no obvious signs of difficulties with his tracheotomy. He required further scans to look for metastases and see whether the treatment the MDT would recommend would be surgical or chemotherapy/radiotherapy. On 10 December 2021 Lee underwent an MRI scan which did pick up an incidental finding of potential emphysema which was not reported. The MRI scan is not the optimal test for picking this up and that was not the purpose of the MRI scan but the potential presence of emphysema on 10th is relevant to later actions. 1 On 14 December 2021 Lee had a PET scan. This scan definitively picked up the presence of emphysema and reported that this was likely as a result of the displaced tracheotomy tube. This scan was reported on the 15 December 2021 and the secretaries at Barnsley Hospital ENT team were contacted by the caseworker from Alliance Medical to notify them that there was a report being sent with a critical finding on. There were delays in the caseworker being identified within Alliance Medical to report the scan to the hospital. When the email was sent from Alliance Medical to the hospital it was not flagged as urgent however the subject line did state 'Critical findings'. The first email did not attach the report and the secretary had to ring Alliance Medical back to request the report which was sent a short time later. This was sent to the Consultant who had given Lee his initial diagnosis. Also on 15 December 2021 Lee began to feel unwell and contact his GP who believed that Lee had a chest infection following a telephone consultation and prescribed antibiotics. He stated that he had a low level of suspicion for the chest infection but did not feel it was necessary to see Lee. He stated that he did not know about that Lee had a tracheotomy although this is recorded within the clinical notes. The Consultant at Barnsley hospital was aware of the critical findings on the scan on 15 December 2021. His initial view was that Lee should not have been allowed to leave hospital or that this was a false positive result. He asked that the nurse, try to ascertain where Lee was and sent her a text requesting her to do this. His view in evidence was that he believed this was a false positive rather than a displaced tube. However the text which was sent states:- 'Sorry to trouble you. It appears on PET that Mr Dryden's tube is not in the trachea. Apparently he was allowed to walk off the premises at NGH. Could you contact him to make sure he is o.K. And encourage him to come in for a review/Re-siting Regards.' This text was sent at 17:49 on 15 December and was not picked up until 09:16 on 16 December 2021. There was therefore no contact made with Lee after the scan findings. Late on 15 December 2021 Lee's mum became so concerned about him that she rang for an ambulance. The ambulance grading was a grade 2 which has an expected response time of 18 minutes with a second target of 9 in 10 grade two calls being responded to in 40 minutes. Lee's call was responded to in 2 hours and 26 minutes. This was due to pressures on the service at the time. This meant that Lee presented at hospital on 16 December 2021 at 00:57 and was very unwell and required treatment for a cardiac arrest. Unfortunately they were unable to ventilate Lee through the tracheotomy as it was not ventilating properly and therefore an additional tube needed to be placed. As a result of the cardiac arrest Lee suffered with a hypoxic brain injury which was ultimately the cause of his death. The failure to take additional steps to contact Lee following the critical findings in the scan on the 15 December 2021 amounts to a gross failure of basic care. Once the findings were known to the consultant body, who clearly felt that Lee required eyes on checking at that time is a basic and ongoing failure which is very very significant. In relation to whether the failure to contact Lee following the scan results being known by the Trust on the 15 December 2021 was causative or contributory to Lee's death in a way that was more than minimally negligibly or trivially. Lee had evidence of emphysema on the MRI scan on 10 December 2021. This was confirmed and attributed to the misplacement of the tube on the 15 December 2021. Lee had therefore potentially managed with the misplaced tube and no ill effects for a number of days. It is apparent to me, on the basis of the evidence that the turning point for Lee was the 15th and 16th December 2021. Had sufficient attempts been made to contact Lee after the scan results were known on the 15th of December 2021 he would have been seen in hospital prior to the cardiac 2 arrest which resulted in the hypoxic brain injury. Although death did not occur for some time after the cardiac arrest, the fatal event was effectively the cardiac arrest on the 16 December 2021. 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. There is Royal College Guidance as to how and by what means the images are reported from external organisations such as Medical Alliance to NHS Trusts however this appears to not be understood or embedded by NHS Trusts. 2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded too within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 27 September 2023. 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: Lee's family, Barnsley District General Hospital, Medical Alliance, Yorkshire Ambulance Service NHS Foundation 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. I may also send a copy of your response to any other 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. 9 2nd August 2023 Abigail Combes 3 4
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 Social Care 39 Victoria Street London SW1H 0EU 20 May 2024 Our Ref: Abigail Combes Assistant Coroner South Yorkshire (West) Coroner’s service, Medico-Legal Centre Watery Street Sheffield S3 7ES By Email: Dear Ms Combes, Thank you for your letter of 2 August 2023 to the Secretary of State for Health and Social Care regarding the death of Lee Dryden. I am replying as Minister with responsibility for urgent and emergency services. Please accept my sincere apologies for the delay in responding to this matter. I would like to assure you that the Department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how deeply sorry I was to read the circumstances Mr Dryden’s death and I offer my sincere condolences to his family. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful to you for bringing these matters to my attention. Your report raised a concern that Royal College guidance on how external providers should report images to NHS trusts was not understood or embedded by NHS trusts. I understand that NHS England, after also receiving your report, has written to you on the specific actions that have been taken or are underway to clarify guidance around imaging reports and how they should be shared between NHS trusts and independent sector providers. In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed. I hope this has provided reassurance on the action being taken on this issue. Your report also raised concerns about response times by Yorkshire Ambulance Service NHS trust (YAS) including the impacts of handover delays. I note NHS England also responded on the action they are taken in relation to this concern. As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to reduce Category 2 ambulance response times to 30 minutes on average. The plan is available at B2034-delivery-plan-for-recovering-urgent-and-emergency- care-services.pdf (england.nhs.uk) Your report highlights that YAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new 1 ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads. Since publication of the plan, we have already seen significant improvements in performance. In 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%. In the Yorkshire region, average Category 2 response times were over 9 minutes faster over the same time period, a 27% reduction. However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this. Thank you once again for bringing these concerns to my attention.
Ms Abigail Combes
South Yorkshire (West) Coroner’s Service
Medico-Legal Centre
Watery Street
Sheffield
S3 7ES
Coroneradmin@rctcbc.gov.uk
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
england.coronersr28@nhs.net
20 September 2023
Re: Regulation 28 Report to Prevent Future Deaths – Lee Dryden who died on
12 January 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2
August 2023 concerning the death of Lee Dryden on 12 January 2022. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Lee’s family and loved ones. NHS England are keen to assure
the family and the coroner that the concerns raised about Lee’s care have been
listened to and reflected upon.
In your Report you raised the concern that Royal College Guidance as to how external
organisations should be reporting images to NHS Trusts was not understood or
embedded by NHS Trusts. NHS England has undertaken or been involved in several
initiatives and activities around imaging reports to improve processes across Trusts
and stakeholder organisations. These include:
• Alerts and Notification of Imaging Reports Recommendations was published in
October 2022 and was supported by a Royal College of Radiology (RCR)
hosted webinar: https://www.rcr.ac.uk/publication/recommendations-alerts-
and-notification-imaging-reports
• NHS England hosted a national webinar on 7th March 2023 with the inclusion
of the above delivered by the RCR for NHS services. This guidance is also
available on the NHS England Futures website, a virtual collaboration platform
for NHS staff members to make change, improve and transform health and
social care.
• The RCR have also indicated they will review the Standards for the Provision
of Teleradiology within the United Kingdom Guidance which was first published
in 2016. This will potentially take place next year.
• The Academy of Medical Royal Colleges (AoMRC) published a report on ‘Alerts
and notification of imaging reports – Recommendations’ which include
recommendations on fail-safe notification systems. This was highlighted by
NHS England in the January 2023 national Patient Safety bulletin and followed
a report from the Healthcare Safety Investigation Branch (HSIB): Failures in
communication or follow-up of unexpected significant radiological findings.
• The NHS England National Imaging Board has developed new standards for
imaging reporting turnaround times which was published on 9th August 2023.
This Radiology Reporting Turnaround Guidance cab be viewed here: . NHS
England » Diagnostic imaging reporting turnaround times. To help embed this
new guidance, a national webinar will be hosted by NHS England on Thursday
28 September and communications will be cascaded across the NHS as well
as to Independent Sector Providers. This will include an update in the national
Patient Safety bulletin.
• NHS England is also investing in digital infrastructure to support Imaging
network development to enable radiology reporting infrastructure across
constituent providers and the independent sector and should link into this
infrastructure for any outsourced Radiology Reporting services.
I acknowledge that the above activities have occurred following Lee’s death in January
2022, but I hope they provide assurances that actions have been taken or are
underway to clarify guidance around imaging reports and how they should be shared
between NHS Trusts and independent sector providers.
My North East & Yorkshire (NEY) regional colleagues have also advised that they
have gone out to all NEY systems for assurance that national guidance is being
followed around image reporting. Systems bring together Nhs organisations, local
authorities and others to take collective responsibility for health and care planning
services across geographical areas.
Your second concern focused on the delay in the Yorkshire Ambulance Service
response time to the ambulance call made by Lee’s mother, which was categorised
as a Category 2 call.
NHS England recognises the significant pressure on ambulance services since the
Covid-19 pandemic, which has seen longer response times across all categories than
before the pandemic. That is why NHS England are focusing on improving ambulance
performance for 2023/24, supported by the Delivery plan for recovering urgent and
emergency care services, published in January 2023. The plan outlines the actions
and steps that we are taking across England to recover and improve urgent and
emergency care services, including improving ambulance response times for
Category 2 incidents, increasing ambulance capacity through growing the workforce,
speeding up discharges from hospitals, expanding new services in the community,
and taking steps to tackle unwarranted variation in performance in the most challenged
local systems.
In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and
Primary Care Networks title Delivering operational resilience across the NHS this
winter. This included focusing on improvements around Accident & Emergency
handover and ambulance handover times.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both
a national and regional level and helps us 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
See every Prevention of Future Deaths report matching Yorkshire Ambulance Service 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.