Source · Prevention of Future Deaths

Lyn Brind

Ref: 2023-0017Deceased Date: 18 Jan 2023 Coroner: Jacqueline Lake Area: Norfolk Responses identified: 1 / 1 View PDF

Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance handover delays.

Date 18 Jan 2023

56-day deadline 15 Mar 2023 est.

Responses identified 1 of 1

Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1) Evidence was heard that there was a delay in Mrs Brind being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital
2) As delays are a reoccurring problem, checks are made by paramedics and Hospital clinicians on patients while they wait in ambulances for transfer into the hospital to assist in prioritising the need for transfer.
3) In the case of Mrs Brind, 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.
4) Further Mrs Brind was not assessed by a Senior Doctor from the Hospital within an hour, in accordance with Hospital protocol
5) I am satisfied that steps have been taken by both EEAST and the Hospital in respect of these matters and do not make a report in respect of either of these matters
6) 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. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays.
7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community.
8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department.
7) 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

Responses

1 respondent

Department of Health and Social Care Central Government

25 Apr 2024 PDF

Action Taken

The Department of Health and Social Care highlights the 'Delivery plan for recovering urgent and emergency care services', investments in virtual wards, and the Discharge Fund to improve patient flow and reduce ambulance handover delays. They note improvements in A&E performance and handover times at the relevant hospital. (AI summary)

View full response

Dear Mrs Lake,

Thank you for your report of 8 January 2023 about the death of Lyn Mary Brind. 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 saddened I was to read of the circumstances of Mrs Brind’s death. I offer my sincere condolences to her families and loved ones. I am grateful to you for bringing these matters to my attention.

The report raises concerns about ambulance handover delays, capacity at Queen Elizabeth Hospital and patient flow through the hospital including the discharging of medically fit patients. Further, I note the report raises concerns regarding appropriate safety checks for patients waiting in ambulances but that you are satisfied with the action taken in respect of these matters by the East of England Ambulance NHS Trust and Queen Elizabeth Hospital King's Lynn NHS Foundation Trust.

I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. The plan also plan also commits to reducing average Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp- content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care- services.pdf

Your report highlights that the hospital was under high demand with long handover delays at the hospital at the time of the incident. I recognise that ambulance trusts work within a health

and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally.

We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.

We have seen improvement in urgent and emergency care performance this year following the delivery plan’s publication. In February 2024 A&E performance at The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust for patients to be admitted, transferred or discharged within 4 hours was 70.7%, an improvement of 8.3 ppt from the same month last year. In March 2024, average handover times in the EEAST region were 30 minutes 12 seconds, an improvement of almost 6 minutes from the previous month. However, I recognise there is still more to do to reduce response times down further and back towards pre-pandemic levels – and this is the action we will continue to be taking as part of the government’s commitment to improving NHS services and reducing waiting times.

Thank you once again for bringing these important issues to my attention.

Yours,

HELEN WHATELY

Report sections

Investigation and inquest

On 07 June 2022 I commenced an investigation into the death of Lyn Mary BRIND aged 61. The investigation concluded at the end of the inquest on 05 January 2023. The medical cause of death was: 1a) Congestive Cardiac Failure 1b) Ischaemic and Hypertensive Heart Disease 1c) Coronary Artery Atherosclerosis and Morbid Obesity
2) Diabetes Mellitus The conclusion of the inquest was: Mrs Brind died from cardiac failure. Her condition was not diagnosed nor treated in a timely fashion.

Circumstances of the death

On 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the Ambulance Navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind's condition continued to deteriorate and she died at 17.52 hours.

Copies sent to

Queen Elizabeth Hospital East of England Ambulance Service NHS Trust (EEAST) Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS ENGLAND (NHS IMPROVEMENT)

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Report details

Reference: 2023-0017Deceased
Date of report: 18 January 2023
Coroner: Jacqueline Lake
Coroner area: Norfolk

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: 15 Mar 2023 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.