Colin Wiles
24 Nov 2024 · Coroner Sally Robinson · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. self neglect leading to poor living conditions
“No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr [name redacted]' comorbities and self neglect leading to poor living conditions and increased risk to his safety”
2. unclear guidance on emergency service callbacks
“It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns”
3. excessive ambulance handover delays
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time”
4. lack of criteria for patient residence and handover
“There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Consideration should be given to strategies to improve handover times at hospitals.”
This report
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Identical hazardConfidence 0.92 · high
This report
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Identical hazardConfidence 0.90 · high
This report
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Responses
2024-0652-Response-from-East-Riding-of-Yorkshire-Council.pdf ↗· East Riding of Yorkshire Council
2024-0652-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2024/25
“Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers are essential to ensure 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 are continuing 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”
2024-0652-Response-from-NHS-Humber-Health-Partnership.pdf ↗· Hull University Teaching Hospital
Stated action · 9th December 2023
“On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times: Phase 1: Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire Ambulance Service (YAS) staff were instructed to leave.”