Source · Prevention of Future Deaths
Madeline Staples
Ref: 2019-0041
Date: 11 Feb 2019
Coroner: John Gittins
Area: North Wales (East and Central)
0 responses identified · 3 indexed addressees
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AI-generated concerns summaryThe coroner raises concerns about persistent, unacceptable delays in patient handovers at the emergency department, causing patients to wait in ambulances and making resources unavailable. These issues have continued despite multiple previous reports and assurances.
Date
11 Feb 2019
56-day deadline
8 Apr 2019
stated in the report
Responses identified
0 of 3
Coroner's concerns
The coroner raises concerns about persistent, unacceptable delays in patient handovers at the emergency department, causing patients to wait in ambulances and making resources unavailable. These issues have continued despite multiple previous reports and assurances.
View full coroner's concerns
_ Following an inquest which concluded in January 2014 issued a regulation 28 report in which expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients kept waiting for long periods in ambulances and ambulance resources consequently unavailable for allocation t0 other calls Coroner'$ Office; County Hall; Wynnstay Road_ Ruthin; LLIS AYN Tel 01824 708047 Fax 01824 708048 delay being being being
In the intervening period from then until the present either or my Assistant Coroners have issued at least a further twelve similar 'regulation 28 reports expressing concerns associated with unacceptable delays and yet despite given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail As has been stated previously in my other reports, recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable_
In the intervening period from then until the present either or my Assistant Coroners have issued at least a further twelve similar 'regulation 28 reports expressing concerns associated with unacceptable delays and yet despite given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail As has been stated previously in my other reports, recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable_
Report sections
Investigation and inquest
On the 11th of April 2018 commenced an investigation into the death of Madeline Constance Staples (DOB 19.7.31 DOD 9.4.2018) The investigation concluded at the end of the inquest on 7lh of February 2019. The conclusion of the inquest was one of an accidental death the Cause of Death being recorded as 1(a) Bronchopneumonia (b) Immobilisation due to Femoral and Tibial Fractures 2. Lung Cancer
Circumstances of the death
On the &th of April 2018 the Deceased (an 86 year old lady) had an unwitnessed fall in her care home. She had sustained long bone fractures of both legs as a result of the fall and the position in which she was lying prohibited her from receiving oral pain relief. An ambulance was called to her assistance at 22.1 hours however due to the absence of available resources (primarily due to lost ambulance hours awaiting discharge of patients at hospital) it was not possible to get assistance to her (and hence some pain relief) until 03.40 hours during which time she remained according to the attending paramedic; "crying out in pain which could be heard from the entrance of the care home despite her room being on the second floor" A second ambulance was required to assist in her removal to hospital and again there was a in this allocated due to an absence of available resources and she did not reach hospital until 05.23 around seven and a quarter hours after the first call for help. Despite treatment for her injuries her condition deteriorated and she died on the guh of April 2019 at 23.20.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Similar PFD reports
Report details
- Reference
- 2019-0041
- Date of report
- 11 February 2019
- Coroner
- John Gittins
- Coroner area
- North Wales (East and Central)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Apr 2019 (stated in the report).
Sent to
- Betsi Cadwaladr University Health Board
- Welsh Ambulance Services NHS Trust
- Ysbyty Gwynedd