Source · Prevention of Future Deaths

Harry Dunn

Ref: 2024-0411 Date: 4 Jul 2024 Coroner: Anne Pember Area: Northamptonshire Responses identified: 1 / 1 View PDF

Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.

Date 4 Jul 2024
56-day deadline 2 Oct 2024 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths

Coroner's concerns

AI summary
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.
View full coroner's concerns
_ a5 follows: (1) When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance_Service Trust EMAS" or_within the neighbouring South Central Ambulance Service Trust The only available emergency medical resource was that run by the Air Ambulance Service Charity which was an advanced medical team based out of Coventry Airport, some c.30 miles away with an estimated arrival time of 57 minutes_ (2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 They had entered a sustained period where demand was outstripping the resources they had available: This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.

(3) Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges_ This is because EMAS'S resources cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.

(4) Iam concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future_

Responses

1 respondent
Department of Health and Social Care Central Government
22 Aug 2024 PDF
Action Planned

DHSC acknowledges ambulance response times are below standard and that the Health Secretary ordered an investigation into NHS performance and a 10-year reform plan. NHS England is taking action to improve performance including maintaining increased ambulance capacity, reducing handover delays, and increasing direct referrals into community services. Regional teams will review EMAS performance. The department will also consider the coroner's concerns when working with NHSE on expanding medicine responsibilities for healthcare professionals. (AI summary)

View full response
Dear Ms Pember, Thank you for your two reports of 4 July regarding the death of Harry Peter Dunn: am replying as Minister with responsibility for urgent and emergency care Firstly , would like to offer my sincere condolences to Mr Dunn's family and loved ones. It is vital that where Regulation 28 reports raise matters of concern, these are looked at carefully so that NHS care can be improved. am grateful for you bringing these matters to my attention. Your reports raise concerns with East Midlands Ambulance Service NHS Trust's (EMAS) response times, and paramedic access to analgesics. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE) and the Medicines and Healthcare products Regulatory Agency (MHRA): understand MHRA will write to you separately regarding the report for which are a direct recipient In relation to ambulance service performance, the Government accepts that response times have been below the high standards that patients should expect in recent years_ The NHS has been broken and it will take time to fix. However; we are determined to do so and have committed to returning urgent and emergency care waiting times to the safe operational waiting time standards set out in the NHS constitution. For Category 2 incidents, this would mean an average response time of 18 minutes compared with current NHS performance (July 2024) of 33 minutes 25 seconds_ As a first the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces. The investigation's findings will feed into the Government's work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future: they step,

In the shorter-term a range f action is being taken by the NHS this year to improve performance including maintaining the increase in ambulance capacity (hours on the road) delivered in 2023/24, where NHSE reported a circa 6% increase year-on-year for December 2023. There is a focus on reducing ambulance handover delays to support patient flow and on increasing direct referrals into community services to reduce conveyance rates to acute hospitals. NHSE has advised my officials that the regional team for the Midlands will continue to have regular review meetings with EMAS including on the support needed to improve response times performance and the quality of care for patients. It is recognised that operational productivity has fallen since the pandemic, and while there was improvement during 2023/24, further improvement is required. The NHS's operational target for 2024-25 is for Category 2 response times to improve to an average of 30 minutes across the year: Regarding your concerns on paramedic access to nasal analgesics, as of 31 December 2023 , paramedic independent prescribers who are registered with the Health and Care Professions Council can prescribe and administer the following five controlled drugs: Morphine sulphate by oral administration or by injection Diazepam by oral administration or by injection Midazolam by oromucosal administration or by injection Lorazepam by injection Codeine phosphate by oral administration Paramedics without an independent prescribing qualification can also administer a range of medicines on their own initiative via exemptions under the Human Medicines Regulations 2012. Please be assured that we will take account of your concerns when agreeing the next steps in our joint work programme with NHSE regarding expanding supply, administration and prescribing of medicines responsibilities for regulated healthcare professionals. Thank you once again for bringing these concerns to my attention

Report sections

Investigation and inquest
On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19. The investigation concluded at the end of the inquest on 13 June 2024. The conclusion of the inquest was: Road Traffic Collision
Circumstances of the death
The circumstances of the death are a5 follows: On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Harry Dunn_ The cause of the collision was that on exiting RAF Croughton inadvertently moved onto the incorrect side of the B4301 rural road and travellled about 350 meters on the wrong side of the road prior to the head o collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton. Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries. He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you (and/or your organisation) have the power to take such action.

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Report details

Reference
2024-0411
Date of report
4 July 2024
Coroner
Anne Pember
Coroner area
Northamptonshire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Oct 2024 (estimated).

Sent to

Department of Health and Social Care

Part of a series

3 reports
2024-0412 All responses identified
2024-0413 1/2

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