Keith Nielsen
PFD Report
All Responded
Ref: 2023-0211
All 2 responses received
· Deadline: 21 Aug 2023
Response Status
Responses
2 of 2
56-Day Deadline
21 Aug 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The MATTER OF CONCERN is: There is a risk of a future reoccurrence of the situation which arose on 21 March 2022 given that SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes.
Responses
Response received
View full response
Dear Madam
Inquests touching the deaths of Mr Keith Nielsen and Mr Ginger Wright
Thank you for providing SECAmb with an opportunity to submit the response to the prevention of future death reports, following the conclusion of the inquests for Mr Nielsen and Mr Wright.
I was saddened to hear of these incidents, and I would like to offer my sincere condolences to the family and friends of Mr Nielsen and Mr Wright.
I note your concern is that “SECAmb is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes”.
South East Coast Ambulance Service NHS Foundation Trust (SECAmb) was commissioned in 2017-18 to provide the 999-emergency service across the three full counties of Kent, Surrey and Sussex, and only part of Hampshire (North-East Hampshire). The scope, size and structure of the service was commissioned based on a comprehensive demand and capacity review undertaken in collaboration with an external organisation based on data from previous years of delivery and planning assumptions.
Prior to the Covid-19 Pandemic SECAmb was performing more favourably against Ambulance Response Programme (ARP) targets, however not consistently meeting all targets. Since early 2019 to the present day, there have been several notable changes in both the way that the public uses the service as well as how the service is operated as part of the wider healthcare environment. Both factors are included in the current development of a new Trust strategy which will be accompanied with a new care delivery model agreed by key stakeholders.
The data shows that there has been a change in demand, and in the profile of patient types, with a significant increase in the proportion of higher acuity/more complex calls, requiring additional resource and clinical expertise. Factors contributing to this
challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand.
It is recognised that to support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across Integrated Care Systems (ICSs). With ICSs becoming legally established in July 2022, this has changed the way Health and Social Care providers work collaboratively and plan delivery of services to their populations, with an increasing focus on public health, improving performance against national and local requirements, and recognising the need for integrated strategies for key areas such as workforce (linked to the recently published NHS Long Term Workforce Plan).
Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:
• Call handling – to achieve the ARP performance targets.
• ARP Category 2 (C2) mean response time– in recognition of the national performance position, all ambulance trusts to deliver a C2 mean performance of a maximum of 30mins by the end of the financial year,
• Hospital handover times – to deliver significant improvement to remove 60min+ handovers and reduce overall handover time and lost hours at hospital due to extended handover times. Whilst SECAmb will continue to focus attention to optimise performance within the current commissioned service, it is recognised that to deliver comprehensive and sustainable improvement a full system-wide review in conjunction with external stakeholders is required, which in turn will lead to a model of care delivery that addresses the current and future requirements of the public across Kent, Surrey, Sussex, and North-East Hampshire.
If I can be of any further assistance, please do not hesitate to contact me.
Inquests touching the deaths of Mr Keith Nielsen and Mr Ginger Wright
Thank you for providing SECAmb with an opportunity to submit the response to the prevention of future death reports, following the conclusion of the inquests for Mr Nielsen and Mr Wright.
I was saddened to hear of these incidents, and I would like to offer my sincere condolences to the family and friends of Mr Nielsen and Mr Wright.
I note your concern is that “SECAmb is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes”.
South East Coast Ambulance Service NHS Foundation Trust (SECAmb) was commissioned in 2017-18 to provide the 999-emergency service across the three full counties of Kent, Surrey and Sussex, and only part of Hampshire (North-East Hampshire). The scope, size and structure of the service was commissioned based on a comprehensive demand and capacity review undertaken in collaboration with an external organisation based on data from previous years of delivery and planning assumptions.
Prior to the Covid-19 Pandemic SECAmb was performing more favourably against Ambulance Response Programme (ARP) targets, however not consistently meeting all targets. Since early 2019 to the present day, there have been several notable changes in both the way that the public uses the service as well as how the service is operated as part of the wider healthcare environment. Both factors are included in the current development of a new Trust strategy which will be accompanied with a new care delivery model agreed by key stakeholders.
The data shows that there has been a change in demand, and in the profile of patient types, with a significant increase in the proportion of higher acuity/more complex calls, requiring additional resource and clinical expertise. Factors contributing to this
challenge include population growth in the southeast, demographic shifts and an aging population. In addition, the pattern of demand is now less aligned to the model commissioned following the review in 2017-18 – whilst rota patterns have been adjusted to improve this alignment, additional staffing numbers are required to meet the change in demand.
It is recognised that to support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across Integrated Care Systems (ICSs). With ICSs becoming legally established in July 2022, this has changed the way Health and Social Care providers work collaboratively and plan delivery of services to their populations, with an increasing focus on public health, improving performance against national and local requirements, and recognising the need for integrated strategies for key areas such as workforce (linked to the recently published NHS Long Term Workforce Plan).
Specifically related to the 2023-24 financial year, SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects. Focus has been specified by NHS England on three functional areas that are:
• Call handling – to achieve the ARP performance targets.
• ARP Category 2 (C2) mean response time– in recognition of the national performance position, all ambulance trusts to deliver a C2 mean performance of a maximum of 30mins by the end of the financial year,
• Hospital handover times – to deliver significant improvement to remove 60min+ handovers and reduce overall handover time and lost hours at hospital due to extended handover times. Whilst SECAmb will continue to focus attention to optimise performance within the current commissioned service, it is recognised that to deliver comprehensive and sustainable improvement a full system-wide review in conjunction with external stakeholders is required, which in turn will lead to a model of care delivery that addresses the current and future requirements of the public across Kent, Surrey, Sussex, and North-East Hampshire.
If I can be of any further assistance, please do not hesitate to contact me.
Response received
View full response
Dear Ms Crawford,
Thank you for your letter of 26 June 2023 to the Secretary of State for Health and Social Care about the death of Keith Nielsen. I am replying as Minister with responsibility for urgent and emergency services. 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 Mr Nielsen’s death and I offer my sincere condolences to his family and loved ones. I am grateful for you bringing these matters to my attention.
Your report raises concerns about ambulance response times by South East Coast Ambulance Trust (SECAmb). I note the trust have provided you with a comprehensive response on the action they are taking locally.
As the Minister responsible for urgent and emergency care services, 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. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce 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 The report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside
the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. 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 have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads. Regarding staffing capacity, we have made significant investments in the ambulance workforce
– the number of NHS ambulance staff and support staff has increased by over 50% since
2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.
At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the same period last year, a reduction of over 27%. In 2023-24, SECAmb performance has also improved and on average the trust’s Category 2 response times have been over 8 minutes faster than the national performance. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the SECAmb region were 18 minutes 41 seconds and is the fourth month in a row that handover time has improved. I also understand the time the trust has spent in surge level 4 has reduced across
2023. However, I recognise there is still more to do to reduce response times further and back towards pre-pandemic levels – improving NHS services and reducing waiting times is a key priority of this Government.
Thank you once again for bringing these important issues to my attention.
Yours,
HELEN WHATELY
Thank you for your letter of 26 June 2023 to the Secretary of State for Health and Social Care about the death of Keith Nielsen. I am replying as Minister with responsibility for urgent and emergency services. 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 Mr Nielsen’s death and I offer my sincere condolences to his family and loved ones. I am grateful for you bringing these matters to my attention.
Your report raises concerns about ambulance response times by South East Coast Ambulance Trust (SECAmb). I note the trust have provided you with a comprehensive response on the action they are taking locally.
As the Minister responsible for urgent and emergency care services, 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. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce 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 The report highlights that SECAmb was under high demand at the time of the incident. A primary aim of our recovery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside
the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly. 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 have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads. Regarding staffing capacity, we have made significant investments in the ambulance workforce
– the number of NHS ambulance staff and support staff has increased by over 50% since
2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.
At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the same period last year, a reduction of over 27%. In 2023-24, SECAmb performance has also improved and on average the trust’s Category 2 response times have been over 8 minutes faster than the national performance. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the SECAmb region were 18 minutes 41 seconds and is the fourth month in a row that handover time has improved. I also understand the time the trust has spent in surge level 4 has reduced across
2023. However, I recognise there is still more to do to reduce response times further and back towards pre-pandemic levels – improving NHS services and reducing waiting times is a key priority of this Government.
Thank you once again for bringing these important issues to my attention.
Yours,
HELEN WHATELY
Report Sections
Investigation and Inquest
An investigation into Mr Nielsen’s death was commenced on 30 March 2022 and an inquest was opened on 5 April 2022. The inquest resumed on 4 April 2023 and concluded on 13 April 2023.
The medical cause of Mr Nielsen’s death was:
1a. Traumatic Brain Injury Causing Bi-Frontal Haemorrhagic Contusions
2. Anti-Coagulant Medication (Warfarin) due to previous Aortic Valve Replacement
The inquest concluded with a narrative conclusion as follows:
‘Mr Nielsen was a 73 year old man who was prescribed the anti-coagulant medication Warfarin. On 20 March 2022 he sustained a head injury due to an unwitnessed fall at his home address. On the morning of 22 March 2022 Mr Nielsen was admitted to East Surrey Hospital and on 23 March 2022 he died at the hospital due to a head injury contributed to by his anti-coagulant medication which exacerbated the bleeding. At 05:33 on 21 March 2022 Mr Nielsen had made a 999 call reporting that he had fallen over and hit his head. South East Coast Ambulance Service (SECAMBS) did not send an ambulance due to a lack of available resources and Mr Nielsen was advised to make his own way to hospital. The 999 call was then closed with a ‘no send’ disposition. However, Mr Nielsen did not make his way to hospital. Mr Nielsen's 999 call was not suitable for a 'no send' disposition because he was on his own with a suspected head injury and had reported a loss of consciousness for a significant period of time in the context of being on warfarin. Further, he had given no clear indication that he was going to make his own way to hospital. In the event that an ambulance had attended to take Mr Nielsen to hospital on 21 March 2022 he would have survived.’
The medical cause of Mr Nielsen’s death was:
1a. Traumatic Brain Injury Causing Bi-Frontal Haemorrhagic Contusions
2. Anti-Coagulant Medication (Warfarin) due to previous Aortic Valve Replacement
The inquest concluded with a narrative conclusion as follows:
‘Mr Nielsen was a 73 year old man who was prescribed the anti-coagulant medication Warfarin. On 20 March 2022 he sustained a head injury due to an unwitnessed fall at his home address. On the morning of 22 March 2022 Mr Nielsen was admitted to East Surrey Hospital and on 23 March 2022 he died at the hospital due to a head injury contributed to by his anti-coagulant medication which exacerbated the bleeding. At 05:33 on 21 March 2022 Mr Nielsen had made a 999 call reporting that he had fallen over and hit his head. South East Coast Ambulance Service (SECAMBS) did not send an ambulance due to a lack of available resources and Mr Nielsen was advised to make his own way to hospital. The 999 call was then closed with a ‘no send’ disposition. However, Mr Nielsen did not make his way to hospital. Mr Nielsen's 999 call was not suitable for a 'no send' disposition because he was on his own with a suspected head injury and had reported a loss of consciousness for a significant period of time in the context of being on warfarin. Further, he had given no clear indication that he was going to make his own way to hospital. In the event that an ambulance had attended to take Mr Nielsen to hospital on 21 March 2022 he would have survived.’
Circumstances of the Death
On the morning of 21 March 2022 Mr Nielsen found himself on the floor at his home address and was unable to remember the previous twelve hours. At 05:33 Mr Nielsen called 999 and at some point that morning he also made an online request for a routine GP appointment. During the 999 call Mr Nielsen reported that he had fallen over and hit his head and could not remember the last twelve hours. He also reported that he took Warfarin. The call handler triaged the call following the NHS pathway which resulted in a Category 3 ambulance response with a target response time of two hours. However, Mr Nielsen was advised to make his own way to hospital and the call was closed as a no send disposition. At 16:18 a GP at Medwyn GP surgery contacted Mr Nielsen by phone in response to his earlier online request for a routine appointment. The GP was not made aware of the fall or the head injury but given that Mr Nielsen was confused during the call and was on Warfarin he asked his receptionist to call an ambulance. At 17:37 a receptionist called and requested an ambulance within two hours. However, an ambulance did not attend until 07:22 the following morning at which time Mr Nielsen was found to be unresponsive. He was taken to East Surrey Hospital, where he was diagnosed with a traumatic brain injury and he died at the hospital on 23 March 2022. On 21 March 2022 SECAMBS was operating at Level 4 of its Surge Management Plan, meaning that demand for the service was significantly outstripping available resources and the service was not capable of responding to calls within target timeframes. The court heard evidence that SECMABS operates a no send policy during Level 4 of its Surge Management Plan whereby Category 3 patients are asked to make their own way to hospital. However, if they are unable to make their own way to hospital - or they refuse to do so - the call is subject to a clinical review and a decision is taken as to whether an ambulance should be sent out to the patient. During his 999 call, Mr Nielsen reported that he was alone, had hit his head and could not remember the last twelve hours. He did not agree to make his own way to hospital.
Accordingly, the court found that a clinical review should have taken place which would have resulted in a category 3 ambulance being assigned to Mr Nielsen. In the event that a category 3 ambulance had been so assigned Mr Nielsen would have survived. Additionally, the court found that there was a significant delay in dispatching an ambulance following the GP surgery’s call to request an ambulance for Mr Nielsen, which was due to SECAMBS being in Level 4 of its Surge Management Plan. Whilst the length of that delay is clearly a matter of concern, it did not materially contribute to Mr Nielsen’s death. The court heard evidence from , Operating Unit Manager at SECAMBS, that the organisation is regularly operating at Level 4 of the Surge Management Plan. He gave evidence that the reasons were multi-factorial and, in particular, he highlighted insufficient staff being available to cover the required operational hours and lengthy delays in hospital handovers leading to a loss of operational hours.
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Accordingly, the court found that a clinical review should have taken place which would have resulted in a category 3 ambulance being assigned to Mr Nielsen. In the event that a category 3 ambulance had been so assigned Mr Nielsen would have survived. Additionally, the court found that there was a significant delay in dispatching an ambulance following the GP surgery’s call to request an ambulance for Mr Nielsen, which was due to SECAMBS being in Level 4 of its Surge Management Plan. Whilst the length of that delay is clearly a matter of concern, it did not materially contribute to Mr Nielsen’s death. The court heard evidence from , Operating Unit Manager at SECAMBS, that the organisation is regularly operating at Level 4 of the Surge Management Plan. He gave evidence that the reasons were multi-factorial and, in particular, he highlighted insufficient staff being available to cover the required operational hours and lengthy delays in hospital handovers leading to a loss of operational hours.
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Copies Sent To
10 Signed
ANNA CRAWFORD
Anna Crawford H.M Assistant Coroner for Surrey Dated this 26th day of June 2023
Inquest Conclusion
‘Mr Nielsen was a 73 year old man who was prescribed the anti-coagulant medication Warfarin. On 20 March 2022 he sustained a head injury due to an unwitnessed fall at his home address. On the morning of 22 March 2022 Mr Nielsen was admitted to East Surrey Hospital and on 23 March 2022 he died at the hospital due to a head injury contributed to by his anti-coagulant medication which exacerbated the bleeding. At 05:33 on 21 March 2022 Mr Nielsen had made a 999 call reporting that he had fallen over and hit his head. South East Coast Ambulance Service (SECAMBS) did not send an ambulance due to a lack of available resources and Mr Nielsen was advised to make his own way to hospital. The 999 call was then closed with a ‘no send’ disposition. However, Mr Nielsen did not make his way to hospital. Mr Nielsen's 999 call was not suitable for a 'no send' disposition because he was on his own with a suspected head injury and had reported a loss of consciousness for a significant period of time in the context of being on warfarin. Further, he had given no clear indication that he was going to make his own way to hospital. In the event that an ambulance had attended to take Mr Nielsen to hospital on 21 March 2022 he would have survived.’
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.