Source · Prevention of Future Deaths

Ronald Hamer

Ref: 2016-0149 Date: 20 Apr 2016 Coroner: Graeme Hughes Area: South Wales Central Responses identified: 1 / 3 View PDF

An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.

Date 20 Apr 2016

56-day deadline 15 Jun 2016 est.

Responses identified 1 of 3

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ 1) As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes_ an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again

2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call: A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8.25pm, 1% hours after the original call had been received_
3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6.50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumslances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves

Responses

1 respondent

Welsh Ambulance Service NHS Trust NHS / Health Body

9 Jun 2016 PDF

Action Planned

The Welsh Ambulance Services NHS Trust has developed an action plan and is monitoring progress through a Task and Finish Group of senior staff, led by the Director of Quality, Safety and Patient Experience. (AI summary)

View full response

Dear Mr Hughes Re Ronald Hamer (Deceased) am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased): would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the actions for improvement. Please find attached copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28. can assure you that as a consequence of this case we have learned lessons as an Organisation which are being monitored through a Task and Finish Group of senior staff, led by the Director of Quality; Safety and Patient Experience: would also like to assure you that the monitoring of the actions and agreed timescales will be scrutinised through the Trust Board Quality, Patient Experience and Safety Committee_ In addition to Regulation 28 requirements would Iike to extend an invite to you to meet with the Director of Operations and the Medical Director who will be able to provide you with an overview of the new and pioneering Clinical Response Model and also the context of the events that were occurring across NHS Wales on the 8 February
2016. Cadcirydd Calr" Ma G0nngs Pnl WeilveuwiChial Extolive Kn Maet Yiddtrdolbaih yn cioasjixu pohadijoln yn Gymre) nout Suasre? Tho Trusl welames coxtospondonce i Welsh pr Evghst LIc key the Trosy (
9141.9

Please do not hesitate to contact me if you have any questions with regards to the action plan:

Report sections

Investigation and inquest

On the 16'h February 2016 opened an inquest into the death of Ronald Hamer_ concluded that inquest on the 13" April 2016. The conclusion of the inquest was Accidental Death

Circumstances of the death

The deceased was an independent elderly gentlemen living at his home at On the morning of Ihe 8th February 2016 he slipped and fell in the bathroom 0f his home sustaining an injury to his right arm. He became immobilised on the floor remaining in an awkward position whereby his right arm was trapped by his body: This incident occurred around Sam and he was not discovered by his family until around 6.45pm over 13'2 hours later. A call to the emergency services was made at around 6.50pm with the ambulance arriving shortly before 9.30pm:. Mr Hamer was conveyed to Prince Charles Hospital in Merthyr Tydfil but despite treatment his condition deteriorated and he died there on the morning of the 10" February 2016

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:

Similar PFD reports

Shared signals

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Report details

Reference: 2016-0149
Date of report: 20 April 2016
Coroner: Graeme Hughes
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jun 2016 (estimated).

Sent to

Health Inspectorate Wales

Minister for Health and Social Services

Welsh Ambulance Services NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.