Kevin Woods
3 Oct 2024 · Coroner Guy Davies · Cornwall and Isles of Scilly
This report repeats 3 earlier warnings, and was raised again 5 times later. See the linked reports.
The coroner's concerns
1. ambulance response delays
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
2. ambulance delays
“There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.”
3. lack of single organisation responsibility
“There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.”
4. absence of overarching organisation
“There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Identical hazardConfidence 0.90 · high
Earlier report
“Evidence heard at [the deceased]'s Inquest indicates that there is a strong relationship between the hours lost due to handover delays and the response times being delivered by SWAST.”
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Repeats an earlier warningJohn Seagrove, Pauline Humphris and Patricia Steggles23 Nov 2023 · 10 months earlier
Identical hazardConfidence 0.90 · high
Earlier report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Identical hazardConfidence 0.90 · high
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Later report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
Closely relatedConfidence 0.85 · high
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Later report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Closely relatedConfidence 0.90 · high
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”
Identical hazardConfidence 0.90 · high
This report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Later report
“Ambulance handover delays affecting emergency availability 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
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Later report
“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
Responses
2024-0531-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action
“making space for a Clinical Decision Unit model, for patients who need more clinical care but don't need to be admitted to hospital”
Stated action
“converting the Same Day Medical Assessment Unit (SDMA) to a Same Day Emergency Care (SDEC) and having a triage process to ensure only patients considered as same day go to the SDEC”
Stated action
“supporting the move of acute medical resource from the emergency department to Acute Medical Unit with the intention of improving short stay performance at the Acute Medical Unit”
Stated action · 2023-24
“maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24”
Stated action
“directing patients to more appropriate services in the community where these can better meet their needs”
Stated action
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”