Michael Clarke

Coroner's concerns

AI summary

Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly for suspected sepsis.

View full coroner's concerns

1. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour. The inquest was told that this was not unusual and was still an ongoing issue. The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays.
2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour.
3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway. The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority.

Responses

1 respondent

NHS England and NHS GMIC

3 May 2024 PDF

Action Planned

NHS England is prioritising improving ambulance performance and is working on improving handover times. The Integrated Care Board will work with CWP and GP colleagues to improve the timeliness and content of correspondence when an individual has contacted the Crisis Line. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Michael Clarke who died on 30 July 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 May 2024 concerning the death of Michael Clarke on 30 July 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Michael’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Michael’s care have been listened to and reflected upon. 

1. National waiting times for ambulances

Your first concern is centred on the significant demand and waiting times for a Category 3 ambulance which was more than four hours rather than the one-hour target. 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, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key actions to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms), alongside broader system actions to improving flow through hospitals and reducing handover delays, speeding up discharges from hospitals and expanding new services in the community, all of which should help ambulance crews to get back on the road to the next waiting patient more rapidly. Whilst ambulance response times have not returned to pre-pandemic levels, there were improvements in ambulance response times nationally during 2023/24. The 2023/24 year-end Category 3 Mean time to respond was 2 hours 4 minutes 14 seconds which is 31 minutes 4 seconds quicker than 2022/23 and the 2023/24 year- end Category 2 Mean was 36 minutes 23 seconds which is 13 minutes 37 seconds quicker than 2022/23. For 2024/25, the Delivery Plan continues to focus on the improvement of ambulance response times, with ambulance services expected to maintain the increases in capacity achieved throughout 2023/24, alongside the continued development of alternative referral pathways (e.g. urgent community response) to ensure that patients receive timely and high-quality care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26 June 2024 A1

2. Categorisation of the ambulance

You also raised a concern that the initial call to North West Ambulance Service (NWAS) was made by an out of hours Nurse who requested an ambulance within one hour as this is consistent with Category 3 response call-outs. It was not considered that on that evening a Category 3 call was not going to result in an ambulance attending within one hour.

When Healthcare Professionals (HCP) request emergency admissions they will be asked several questions to determine the category of response required. Michael was conscious, breathing and it was confirmed there was no threat to life, limb or sight requiring immediate emergency admission. An HCP Category 3 ambulance response was generated and following audit this was found to be safe and appropriate. At the time the estimated response time was 4 hours 15 minutes, and this was communicated to the HCP requesting admission. If a decision is made to upgrade a call from the allocated category this could severely impact the response given to calls allocated a higher priority with their initial triage on their patient's current presentation.

The further 999 calls received for Michael were triaged by NWAS call takers utilising NHS Pathways to determine the correct categorisation for the patient's presentation. Audit confirmed the Category 3 outcome was appropriate to the second call. When the patient deteriorated NWAS were contacted back as per escalation advice.

3. Sepsis trigger questions on the ambulance pathway

Your third concern raised was regarding there being no specific sepsis questions on the ambulance pathway. The NHS Pathways triage system is a clinical decision support system (CDSS) supporting the assessment of patients presenting to urgent and emergency services, such as ambulance services. The system is owned by the Department for Health and Social Care and delivered by the Transformation Directorate of NHS England.

NHS Pathways’ clinical content updates and changes are overseen by an independent National Clinical Advisory Group (NCAG). This is hosted by the Academy of Medical Royal colleges and is chaired by the Royal College of General Practitioners. That group includes experts from professional bodies, including the Royal College of Emergency Medicine. Alongside this independent oversight, NHS England ensures that the clinical content and assessment protocols in the NHS Pathways system are consistent with the latest advice from respected bodies that provide evidence and guidance for clinical practice in the UK. This includes latest guidelines from NICE (National Institute for Health and Care Excellence), the UK Resuscitation Council and the UK Sepsis Trust.

Sepsis is considered in many routes in the NHS Pathways CDSS. The product offers all callers a symptom-based assessment (whether members of the public or healthcare professionals (HCP)) based on a clinical hierarchy presenting a series of questions in order that the most appropriate clinical response or disposition may be determined based on the presenting symptoms. Following the implementation of the Ambulance Response Programme response model, NHS England published a A2

national framework which NHS Pathways adhere to, relating to ambulance responses for Healthcare Professionals (HCPs) requesting ambulances, and sets out four levels of response.

Where the caller is an HCP, calling to arrange an emergency ambulance or non-urgent transfer, full symptom-based assessment is offered but is not mandatory. Rather, if the HCP requests dispatch of emergency services but does not require further help with assessing the patient’s symptoms, then they are asked to specify the main problem (illness, injury, or other health problem) and this is documented by free text into the assessment record. Even if full assessment is not required questions present to identify time-sensitive conditions, where delay is likely to be associated with significant clinical deterioration. This includes an option to select “suspected sepsis, septicaemia or meningitis” – which should have been the case in this instance.

NEWS2 is a tool that is for use in both acute hospital and ambulance settings NHS England » National Early Warning Score (NEWS) . Whilst NEWS2 is not the same as ‘trigger questions’ the clinical indicators needed to inform a NEWS2 score are of similar effect. On selecting “suspected sepsis, septicaemia, or meningitis” the HCP will be asked for the patient’s NEWS score1. A NEWS score of 7 or above generates a Category 2 ambulance response, in concordance with the national framework for healthcare professional ambulance responses2. A NEWS score of 5 or 6 will also generate a Category 2 response in the presence of ‘suspected sepsis, septicaemia or meningitis’ being previously identified. Where the NEWS score is unknown, or is below 5, the HCP will be asked if there is a clinical reason why an emergency ambulance must be dispatched immediately. If the clinician specifies a clinical reason, then this is documented within the assessment and a Category 2 response is generated. This ensures that the clinical judgement of the HCP (who has knowledge of individual patient risk factors and circumstances) is considered when an emergency response is requested. For those with no clinical reason identified as requiring an immediate Category 2 emergency response at this point, triage will continue to identify whether a 1,2-,3- or 4-hour response is needed.

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.

1 The National Early Warning Score, NEWS, is a system in widespread use by clinicians and ambulance trusts across England to identify acutely ill patients, including those with sepsis. 2 https://www.england.nhs.uk/wp-content/uploads/2019/07/C1172-aace-national-framework-for-hcp- ambulance-responses.pdf A3

Report sections

Investigation and inquest

On 1st August 2023 I commenced an investigation into the death of Michael Clarke. The investigation concluded on the 28th March 2024 and the conclusion was one of Narrative: Died from the complications of urosepsis following a previous medical procedure, contributed to by his underlying health conditions. The medical cause of death was 1a) Multiple organ failure 1b) Urosepsis on the background of a cystoscopy on 26/07/23 II) Diabetes mellitus, end stage kidney disease, atrial fibrillation, hypertension.

Circumstances of the death

Michael Clarke had a complex medical history that included diabetes, end stage renal failure, hypertension, and atrial fibrillation. He required dialysis three times a week. On 20th July 2023 Michael Clarke saw his GP for a suspected urinary tract infection and reported blood in his urine. He was prescribed antibiotics for the suspected infection and referred on the 2 week pathway for investigation of the cause of the bleeding. On 26th July 2023 he was seen in the cystoscopy clinic under the 2 week wait referral pathway. The urine culture from the sample on 21st July showed mixed growth. The cystoscopy found no evidence of cancer although there was evidence of significant bladder debris that was cleared out. On 28th July 2023 Michael Clarke felt very unwell. At 21:20 a call was placed to Northwest Ambulance Service by the out of hours nurse indicating they were concerned he had sepsis and an ambulance was required. The call was categorised as a category 3 which meant an ambulance should have been dispatched in 1 hour. Due to demand the wait was in excess of 4 hours. The nurse indicated 1 hour was an acceptable time frame. After 1 hour no ambulance attended and a further call was made. The category remained at 3. At 23:38 a further call was made and the call was categorised as a category 2 call. An ambulance arrived and took him to hospital. At Tameside General Hospital he was diagnosed with suspected urosepsis probably triggered by the cystoscopy. He was started on intravenous antibiotics and was moved to the Intensive Care Unit for full organ support. He continued to deteriorate and died at Tameside General Hospital on 30th July 2023. 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 will 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. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour. The inquest was told that this was not unusual and was still an ongoing issue. The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays.
2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour.
3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway. The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority.

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