Lyn Brind
18 Jan 2023 · Coroner Jacqueline Lake · Norfolk
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. delayed transfer of patients from ambulance to emergency department
“Evidence was heard that there was a delay in Mrs [name redacted] being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital”
2. failure to monitor and escalate patient deterioration
“physiological observations were not undertaken regularly in accordance with East of England Ambulance Service Trust (EEAST) Guidance and when they were taken, her high NEWS2 score was not escalated to the Hospital Ambulance Navigator who assesses priority for beds in the hospital”
3. delayed senior medical assessment
“Further Mrs [name redacted] was not assessed by a Senior Doctor from the Hospital within an hour, in accordance with Hospital protocol”
4. overcrowded emergency department
“Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transfer patients into the Emergency Department”
5. ambulance queue causing delayed care
“at the time of Mrs [name redacted] death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital”
6. beds occupied by non-acute patients
“Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Emergency department crowding is associated with increased mortality amongst admitted patients;”
This report
“Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transfer patients into the Emergency Department”
Closely relatedConfidence 0.90 · high
This report
“Evidence was heard that there was a delay in Mrs [name redacted] being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital”
Later report
“The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Identical hazardConfidence 0.90 · high
This report
“Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community.”
Later report
“Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge.”
Identical hazardConfidence 0.95 · high
This report
“Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community.”
Later report
“On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.”
Responses
2023-0017-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · across this fiscal year
“also plan also commits to reducing average Category 2 ambulance response times to 30 minutes across this fiscal year.”