Source · Prevention of Future Deaths

Celia Sanderson

Ref: 2023-0052Deceased Date: 10 Feb 2023 Coroner: Alison Mutch Area: Manchester South Responses identified: 2 / 1 View PDF

Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.

Date 10 Feb 2023

56-day deadline 7 Apr 2023 est.

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths

Coroner's concerns

AI summary

Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.

View full coroner's concerns

1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time. The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them;
2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors. Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced. Historically that had been a quieter period however demands on ED meant that was no longer the case. As a consequence senior reviews of patients were further delayed. An earlier review by a senior clinician was the inquest heard likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate;
3. Evidence given to the inquest indicated that the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed to ensure a timely transfer to a trauma unit. The inquest heard that timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient. The inquest was told that once CT scans were requested there were often delays due to a shortage of suitably qualified staff to carry them out and then to report on them. As an example of this the inquest was told that overnight 1 radiology registrar was responsible for reporting on CT scans for 3 hospitals (Wythenshawe, the MRI and RMCH) In Mrs Sanderson’s case this meant that the ED clinician had to wait for it to be carried out and then assess the CT scan without the report;
4. The inquest heard evidence from a trauma specialist about the importance of recognising “silver trauma”. There was recognition amongst trauma specialists of the high risk of significant trauma amongst elderly patients such as Mrs Sanderson even from what could appear to be relatively minor incidents. As a consequence major trauma centres generally had developed protocols that assisted staff at triage to pick up such cases and prioritise them and set a low threshold for an early CT scan. Such protocols were not generally in force in DGH settings. The evidence was that there needed to be steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival in order to expedite discussion with and transfer to a trauma centre and increase the chances of survival.

Responses

2 respondents

NHS England NHS / Health Body

10 Feb 2023 PDF

Noted

NHS England acknowledges the concerns, discusses Greater Manchester Integrated Care's challenges, and points to national guidance on UEC recovery. The Regulation 28 Working Group will share learnings nationally. (AI summary)

View full response

Dear Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Celia Sanderson who died on 09 July 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10 February 2023 concerning the death of Celia Sanderson on 9 July 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Celia’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Celia’s care have been listened to and reflected upon.

I am grateful for the further time to respond to your Report, and I apologise for any anguish this delay may have caused to Celia’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations. Demands on Service Urgent and emergency care (UEC) access standards are challenged at NHS GM, where bed occupancy rates continue to be high, impacting upon flow. Significant numbers of hospital beds are occupied by people who no longer require medical treatment, but who do not have a suitable place to be discharged to. This in turn means that flow through UEC slows, and the demand on staff and resources increases. Patient safety and experience can be impacted by these delays and as a result, staff resilience is also affected. A deep dive was undertaken into urgent care by the Greater Manchester Integrated Care Quality and Performance Committee in January 2023. Deep dives present an opportunity for quality and performance teams to work with system boards and provider partners to set out the key deliverables, challenges, risks, and impact on National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

05 MAY 2023

safety in relation to a specific service as well as provide an update against improvement programmes and plans. To inform this deep dive, a wide range of intelligence was reviewed including quantitative and qualitative information. Qualitative information reviewed included but was not limited to learning from reports to prevent future deaths and serious incidents, complaint themes, and the friends and family test. Further information on this deep dive can be found here: gm-quality-and-performance- committee-january-2023-public-meeting-pack.pdf (gmintegratedcare.org.uk) NHS GM have established an Urgent Emergency Care (UEC) action plan led by the Urgent Care Board strategically and the System Operational Response Taskforce (SORT) from an operational perspective. This is an evolving action plan which now includes industrial action as a feature of operational planning, including managing the impact of staff strikes. The action plan is in line with NHS England’s national requirements as set out in our guidance "Going further on our winter resilience plans" first published in October 2022 and updated in December 2022. NHS GM and its wider system partners remain focussed on responding to pressures, utilising additional funding to ensure safe and effective urgent care. Systems are working at Organisation, Place, and Integrated Care System (ICS) level to deliver this. In addition to the national requirements, NHS GM has been sharing and implementing best practice and monitoring impact on some additional metrics:
• 111 call abandonment (the call is ended before a conversation has occurred).
• Mean 999 call answering times.
• Category 2 ambulance response times, these calls are triaged as an emergency or potentially serious condition. These calls are responded to within an average of 18 minutes.
• Average hours lost to ambulance handover delays per day.
• Adult general and acute type 1 bed occupancy (adjusted for void beds)
• Percentage of beds occupied by patients who no longer meet the criteria to remain an inpatient.
• Delivering safe and effective care through winter (focussed winter metrics) Learning from Deaths In relation to this Regulation 28, NHS England have been informed that the learning is to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and National Institute for Health and Care Excellence (NICE). Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums. Despite the NHS being under pressure, which is expected to continue, the NHS GM has provided NHS England with assurances that they will continue to improve care quality for all patients.

The learning from the investigation into this incident has also been interrogated and used to improve practice. It has been shared with the Greater Manchester Major Trauma Network to inform learning and improvement (see below). Trauma Network & Multi-Disciplinary Support We understand that NHS GM formed a Greater Manchester Major Trauma Network (GM MTN) in April 2012. It is a coordinated and inclusive collaborative partnership between staff, services and organisations in Greater Manchester that provide care to patients who have sustained major trauma injuries. Its purpose is to deliver safe, equitable and effective care to patients who have suffered serious, and often multiple, injuries where there is a strong possibility of death or disability. The network management team consists of a Quality Improvement Lead, Network Manager and Network Administrator. Clinical leadership is provided by a Network Medical Lead. Within the Trauma Network there are also consultant leads for rehabilitation, governance, surgery as well as frailty. All NHS hospitals and pre-hospital services in Greater Manchester who provide trauma care are members of the Network. Hospitals provide a different function depending on the services they have on site – there are two adult major trauma centres (MTCs), three major trauma units (TUs) and six local emergency hospitals (LEHs) within Greater Manchester. As a clinical network, they are part of the GM Critical Care & Major Trauma Operational Delivery Network (ODN). The ODN is funded by commissioners of specialised services at NHS England and NHS Improvement. The ODN is hosted by Manchester University NHS Foundation Trust: https://www.gmccmt.org.uk/major-trauma/about/. As mentioned above, NHS England have been advised that the learning from the investigation into this incident is to be used to improve practice across the Trauma Network for Greater Manchester. National Guidance on UEC Recovery NHS England has recently published the Delivery plan for recovering urgent and emergency care services. This plan recognises that urgent and emergency care services have been through the most testing time in the history of the NHS; that patients have been spending longer in Accident & Emergency departments than they should; and that flow, within some hospitals, is slower than it should be. In relation to the concerns identified by HM Coroner in terms of demand on urgent and emergency care services, the published plan sets out the steps that the NHS are taking to respond to this demand safely. Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties.

I would also like to provide further assurances on the 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 events, such as the sad death of Celia are shared across the NHS at both national and regional level and helps us to 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.

Department of Health and Social Care Central Government

3 Jul 2024 PDF

Noted

The Department of Health and Social Care acknowledges the concerns raised, noting that NHS England has addressed them, including action taken locally and a Major Trauma Network. They highlight national initiatives for urgent and emergency care improvements. (AI summary)

View full response

Dear Ms Mutch,

Thank you for your letter of 10 February 2023 regarding the death of Celia Sanderson. I am replying as Minister with responsibility for urgent and emergency care. Please accept my sincere apologies for the significant delay in responding to this matter. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency.

Firstly, I would like to say how deeply sorry I was to read of the circumstances of Ms Sanderson’s death, and I offer my sincere condolences to her 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. I am grateful to you for bringing these matters to my attention.

Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.

NHSE recognises the importance of identifying and supporting older people with frailty and is working to improve and standardise these services. They have committed to ensuring all Type 1 providers have an acute frailty service in place for at least 10 hours a day, 7 days a week. These services will implement a comprehensive geriatric

2 assessment at the front door as well as the minimum standards in the FRAIL strategy. More information on the FRAIL strategy can be seen here: NHS England » FRAIL strategy. NHSE have also recently launched the non-ambulatory fragility fracture (NAFF) pathway to underpin the delivery of care for older orthopaedic trauma patients. More information can be seen here: Non Ambulatory Fragility Fracture pathway.

Departmental officials have also made enquiries with the Care Quality Commission (CQC), who reviewed your report in line with their Regulation 28 guidance. The CQC has taken no specific regulatory action in this case and is continuing its ongoing monitoring and engagement with the Manchester University NHS Foundation Trust.

As Minister with responsibility for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. In January 2023, NHS England published a two year ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times with targets for this year for a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at: NHS England » Urgent and emergency care recovery plan year 2: building on learning from 2023/24.

To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.

Since publication of the plan in January 2023, there have been improvements in performance. National average A&E 4-hour performance has improved from 70.8% in 2022/23 to 72.1% in 2023/24.

Thank you once again for bringing these concerns to my attention.

Yours,

Report sections

Investigation and inquest

On 12th July 2022 I commenced an investigation into the death of Celia Sanderson. The investigation concluded on the 12th January 2023 and the conclusion was one of Narrative: Died from injuries sustained in a road traffic collision where there was a delay in identifying the severity of the injuries sustained. The medical cause of death was 1a) Acute Myocardial Infarction; 1b) Multiple Injury, Acute Bilateral Subdural Haematomas; 1c) Road Traffic Collision

Circumstances of the death

Celia Sanderson was involved in a Road Traffic Collision. She was then taken to Wythenshawe Hospital. There was a delay in triage due to demands on the Emergency Department. Triage did not pick up on her being a potential silver trauma case. A CT scan was not ordered at that time. She was triaged to be seen within 1 hour. Due to demands on the Emergency Department she was not seen by a clinician until approximately 6 hours after triage. This was not a senior clinician assessment due to staffing levels and demands on the department. The junior doctor found no significant injuries but asked for a more senior review. This was delayed due to the workload demands on the middle grade doctor. On assessment the middle grade doctor identified a CT scan was required. The CT scan was requested at 04.21. The scan was reviewed by a clinician at 7am before the radiology report itself was available. The actual report was delayed due to workload demands on the radiology registrar. It was identified that she had severe injuries from the road traffic collision and a transfer to a major trauma centre was required. Celia Sanderson began to deteriorate whilst further tests were undertaken and awaiting transfer. The further tests identified she had also sustained significant neurological damage from the road traffic collision. She continued to deteriorate and had an acute myocardial infarction. She died at Wythenshawe Hospital before she could be transferred. 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. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time. The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them;
2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors. Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced. Historically that had been a quieter period however demands on ED meant that was no longer the case. As a consequence senior reviews of patients were further delayed. An earlier review by a senior clinician was the inquest heard likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate;
3. Evidence given to the inquest indicated that the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed to ensure a timely transfer to a trauma unit. The inquest heard that timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient. The inquest was told that once CT scans were requested there were often delays due to a shortage of suitably qualified staff to carry them out and then to report on them. As an example of this the inquest was told that overnight 1 radiology registrar was responsible for reporting on CT scans for 3 hospitals (Wythenshawe, the MRI and RMCH) In Mrs Sanderson’s case this meant that the ED clinician had to wait for it to be carried out and then assess the CT scan without the report;
4. The inquest heard evidence from a trauma specialist about the importance of recognising “silver trauma”. There was recognition amongst trauma specialists of the high risk of significant trauma amongst elderly patients such as Mrs Sanderson even from what could appear to be relatively minor incidents. As a consequence major trauma centres generally had developed protocols that assisted staff at triage to pick up such cases and prioritise them and set a low threshold for an early CT scan. Such protocols were not generally in force in DGH settings. The evidence was that there needed to be steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival in order to expedite discussion with and transfer to a trauma centre and increase the chances of survival.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0052Deceased
Date of report: 10 February 2023
Coroner: Alison Mutch
Coroner area: Manchester South

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Apr 2023 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.