Kevin Woods
PFD Report
All Responded
Ref: 2024-0531
All 1 response received
· Deadline: 28 Nov 2024
Response Status
Responses
1 of 1
56-Day Deadline
28 Nov 2024
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
1) Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.
2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.
3) There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.
4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.
2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays.
3) There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.
4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.
Responses
Response received
View full response
Dear Mr Davies,
Thank you for the Regulation 28 report of 3 October 2024 sent to the Secretary of State for Health and Social Care about the death of Kevin Woods. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Woods’ death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns regarding delayed transfers of care to hospital by ambulances and poor emergency department performance due to patient flow and discharge issues at Royal Cornwall Hospitals NHS Trust (RCHT). I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament.
In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
I understand that RCHT is implementing urgent changes to improve patient flow and care through the emergency department. Priority actions include:
• making space for a Clinical Decision Unit model, for patients who need more clinical care but don’t need to be admitted to hospital.
• converting the Same Day Medical Assessment Unit (SDMA) to a Same Day Emergency Care (SDEC) and having a triage process to ensure only patients considered as same day go to the SDEC.
• supporting the move of acute medical resource from the emergency department to Acute Medical Unit with the intention of improving short stay performance at the Acute Medical Unit.
The overall urgent care position in the region is supported by ongoing actions, including a system clinical leaders’ event in August which focussed on clinically led plans to maximise community alternatives and update models to improve the urgent care access standards for Cornwall. The Chief Operating Officer at RCHT reports weekly on improvement actions being taken. At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
This government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.
We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.
Turning to your concern regarding organisational responsibilities, health and care systems and providers should work together to ensure that efforts to discharge individuals from hospital into social care are joined up and make best use of available resources, in line with the duty to cooperate set out in Section 82 of the NHS Act 2006.
The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 3 October 2024 sent to the Secretary of State for Health and Social Care about the death of Kevin Woods. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Woods’ death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns regarding delayed transfers of care to hospital by ambulances and poor emergency department performance due to patient flow and discharge issues at Royal Cornwall Hospitals NHS Trust (RCHT). I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament.
In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
I understand that RCHT is implementing urgent changes to improve patient flow and care through the emergency department. Priority actions include:
• making space for a Clinical Decision Unit model, for patients who need more clinical care but don’t need to be admitted to hospital.
• converting the Same Day Medical Assessment Unit (SDMA) to a Same Day Emergency Care (SDEC) and having a triage process to ensure only patients considered as same day go to the SDEC.
• supporting the move of acute medical resource from the emergency department to Acute Medical Unit with the intention of improving short stay performance at the Acute Medical Unit.
The overall urgent care position in the region is supported by ongoing actions, including a system clinical leaders’ event in August which focussed on clinically led plans to maximise community alternatives and update models to improve the urgent care access standards for Cornwall. The Chief Operating Officer at RCHT reports weekly on improvement actions being taken. At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
This government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.
We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.
Turning to your concern regarding organisational responsibilities, health and care systems and providers should work together to ensure that efforts to discharge individuals from hospital into social care are joined up and make best use of available resources, in line with the duty to cooperate set out in Section 82 of the NHS Act 2006.
The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Report Sections
Investigation and Inquest
On 19 January 2024 I commenced an investigation into the death of 64-year-old Kevin Woods. The investigation concluded at the end of the inquest on 30 September 2024.
The medical cause of death was found as follows:
1a. Hypertensive heart disease
The four questions - who, when, where and how – were answered as follows:
Kevin George WOODS died on 17 January 2024 at from complications of an undiagnosed heart condition following an ambulance delay which denied Kevin the opportunity of potentially lifesaving treatment. Kevin’s family made a 999-call requesting an ambulance at 22:24 hours on 16 January 2024, at which time Kevin was exhibiting clear symptoms of a heart attack. The ambulance service allocated Kevin a category 2 priority but there were no ambulances available on that category. Kevin went into cardiac arrest at 02:33 hours on 17 January 2024 and subsequently became unresponsive. The ambulance service re-categorised the call as category 1 and despatched an ambulance. A Paramedic Support Vehicle arrived at 02:44 hrs on 17 January 2024 whilst the family were giving Kevin CPR. The paramedics continued CPR but were unable to save Kevin’s life. Kevin was pronounced deceased at the scene at 03:31 hrs that day. There was a response delay of 4 hours and 16 minutes from the original category 2 priority decision to the arrival of the paramedic support vehicle. Information Classification: PUBLIC Kevin’s heart condition was possibly treatable, and the ambulance delay denied him the opportunity of potentially lifesaving treatment. The ambulance delay was attributable to a systemic failure related to the whole system of health and social care.
The narrative conclusion of the Inquest was as follows:
Kevin died from an undiagnosed and possibly treatable heart condition, following an ambulance delay attributable to a systemic failure related to the whole system of health and social care. The ambulance delay was possibly causative of death in that it denied Kevin potentially lifesaving treatment.
The medical cause of death was found as follows:
1a. Hypertensive heart disease
The four questions - who, when, where and how – were answered as follows:
Kevin George WOODS died on 17 January 2024 at from complications of an undiagnosed heart condition following an ambulance delay which denied Kevin the opportunity of potentially lifesaving treatment. Kevin’s family made a 999-call requesting an ambulance at 22:24 hours on 16 January 2024, at which time Kevin was exhibiting clear symptoms of a heart attack. The ambulance service allocated Kevin a category 2 priority but there were no ambulances available on that category. Kevin went into cardiac arrest at 02:33 hours on 17 January 2024 and subsequently became unresponsive. The ambulance service re-categorised the call as category 1 and despatched an ambulance. A Paramedic Support Vehicle arrived at 02:44 hrs on 17 January 2024 whilst the family were giving Kevin CPR. The paramedics continued CPR but were unable to save Kevin’s life. Kevin was pronounced deceased at the scene at 03:31 hrs that day. There was a response delay of 4 hours and 16 minutes from the original category 2 priority decision to the arrival of the paramedic support vehicle. Information Classification: PUBLIC Kevin’s heart condition was possibly treatable, and the ambulance delay denied him the opportunity of potentially lifesaving treatment. The ambulance delay was attributable to a systemic failure related to the whole system of health and social care.
The narrative conclusion of the Inquest was as follows:
Kevin died from an undiagnosed and possibly treatable heart condition, following an ambulance delay attributable to a systemic failure related to the whole system of health and social care. The ambulance delay was possibly causative of death in that it denied Kevin potentially lifesaving treatment.
Circumstances of the Death
1. The findings of fact on how Kevin died are set out above in the answers to the four statutory questions.
Systemic failure and Kevin’s death
2. The court made findings of fact upon the wider circumstances, namely the systemic failure that was possibly causative of Kevin’s death.
3. On the day the ambulance call was made there were considerable ambulance delays. Whilst Kevin’s priority remained category 2, during the period from the original 999 call to the onset of cardiac arrest (over four hours) there were no ambulances available for Kevin.
4. The national target set by the Department of Health is to attend Category 2 incidents within 40 minutes on at least 90% of occasions, with an average response of 18 minutes. Kevin waited over four hours and the reason the ambulance then attended was because Kevin’s case was re-prioritised to Category 1 following the cardiac arrest.
5. Data provided to the court suggested that on the 16th January 2024 some Category 2 calls were having to wait 6 hours for an ambulance.
6. At approximately the time the ambulance call was made, 23:00 hours, there were 33 incidents awaiting allocation in Cornwall, including 20 that were Category 2. At this time South West Ambulance Service Trust (SWAST) reported that all ambulance resources were either responding to calls or delayed at hospitals (in the patient handover process). At the two main receiving hospitals for Cornwall, there were 12 ambulances delayed at Plymouth hospital and 22 ambulances delayed at Truro Royal Cornwall Hospital (RCHT). At this time SWAST was 123% resourced for anticipated demand in Cornwall, with a total of 45 ambulances available. This means approximately half of the allocated ambulances for Cornwall were delayed at RCHT.
7. The court found that the hospital has regularly failed to meet the 4-hour target for moving patients out of the Emergency Department (ED) during 2024. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed.
8. The court found insufficient bed availability on acute wards was attributable to an increase in patients with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.
9. Approximately 80% of NCTR patients at RCHT are of that status for external reasons beyond the control of RCHT. The main causes of external NCTR numbers were found to be as follows:
• Social care provision (whether commissioned by social services or NHS) namely packages of care in the community, beds in nursing homes or residential care homes
• NHS primary healthcare support for discharge (in the home)
• NHS community hospital provision Information Classification: PUBLIC
10. The court found significant correlation between delayed discharges, handover delays and delays in ambulance response times. On this basis, the court found there was a direct connection between the ambulance delay and inadequate social care provision, community hospital provision and primary healthcare support.
11. The connection between delayed discharges and ambulance delays and the associated risks has been referred to in reports from Southwest Ambulance Service Trust (SWAST) and the Health Services Safety Investigations Body (HSSIB). The court found that the state knew or ought to know of the risks.
Current circumstances of systemic failure
12. The findings of fact upon current circumstances in relation to the systemic failure were as follows.
13. There was found to be a direct connection between current ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support on discharge. This is because inadequacies in those services lead to delayed discharges from hospital which lead to shortages of acute beds, impeded patient flow, crowding in ED and the inability of ambulances to handover patients to ED.
14. Significant average handover delays at RCHT were recorded for every month of 2024. This is a picture reflected across the SW and indeed nationally.
15. The average handover delays conceal spikes such as that which led to the long delay in this case. Such long delays increase the risk of mortality.
16. There are continuing delays of patients from ED which is evidenced by the ongoing failure to regularly meet the 4-hour standard. These delays increase the risk of mortality.
17. Over the last year up to 16% of patients in RCHT have been of external NCTR status, patients who meet the criteria for discharge but cannot be discharged for reasons external to RCHT.
18. The court found that if the external NCTR numbers could be reduced, this would significantly address current issues of ambulance delays, ED crowding, and the shortage of acute beds.
19. The main drivers of external NCTR patients are inadequate social care provision, community hospital provision and primary healthcare support on discharge.
20. The court noted the SWAST systems report which found… ‘’….there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.’’
21. Approximately 10% of social care posts in Cornwall are currently vacant notwithstanding Cornwall Council securing the agreement of social care providers to pay the living wage. This reflects the national picture of 165,000 vacant social care posts.
22. The extent of the obligation on local authorities is set out in the Care Act s5 A local authority must promote the efficient and effective operation of a market in services for meeting care and support needs with a view to ensuring [inter alia] …. a variety of high quality services to choose from…
23. The NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market.
24. The organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision, primary healthcare provision and community hospital provision. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
25. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm. Information Classification: PUBLIC
Systemic failure and Kevin’s death
2. The court made findings of fact upon the wider circumstances, namely the systemic failure that was possibly causative of Kevin’s death.
3. On the day the ambulance call was made there were considerable ambulance delays. Whilst Kevin’s priority remained category 2, during the period from the original 999 call to the onset of cardiac arrest (over four hours) there were no ambulances available for Kevin.
4. The national target set by the Department of Health is to attend Category 2 incidents within 40 minutes on at least 90% of occasions, with an average response of 18 minutes. Kevin waited over four hours and the reason the ambulance then attended was because Kevin’s case was re-prioritised to Category 1 following the cardiac arrest.
5. Data provided to the court suggested that on the 16th January 2024 some Category 2 calls were having to wait 6 hours for an ambulance.
6. At approximately the time the ambulance call was made, 23:00 hours, there were 33 incidents awaiting allocation in Cornwall, including 20 that were Category 2. At this time South West Ambulance Service Trust (SWAST) reported that all ambulance resources were either responding to calls or delayed at hospitals (in the patient handover process). At the two main receiving hospitals for Cornwall, there were 12 ambulances delayed at Plymouth hospital and 22 ambulances delayed at Truro Royal Cornwall Hospital (RCHT). At this time SWAST was 123% resourced for anticipated demand in Cornwall, with a total of 45 ambulances available. This means approximately half of the allocated ambulances for Cornwall were delayed at RCHT.
7. The court found that the hospital has regularly failed to meet the 4-hour target for moving patients out of the Emergency Department (ED) during 2024. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed.
8. The court found insufficient bed availability on acute wards was attributable to an increase in patients with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.
9. Approximately 80% of NCTR patients at RCHT are of that status for external reasons beyond the control of RCHT. The main causes of external NCTR numbers were found to be as follows:
• Social care provision (whether commissioned by social services or NHS) namely packages of care in the community, beds in nursing homes or residential care homes
• NHS primary healthcare support for discharge (in the home)
• NHS community hospital provision Information Classification: PUBLIC
10. The court found significant correlation between delayed discharges, handover delays and delays in ambulance response times. On this basis, the court found there was a direct connection between the ambulance delay and inadequate social care provision, community hospital provision and primary healthcare support.
11. The connection between delayed discharges and ambulance delays and the associated risks has been referred to in reports from Southwest Ambulance Service Trust (SWAST) and the Health Services Safety Investigations Body (HSSIB). The court found that the state knew or ought to know of the risks.
Current circumstances of systemic failure
12. The findings of fact upon current circumstances in relation to the systemic failure were as follows.
13. There was found to be a direct connection between current ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support on discharge. This is because inadequacies in those services lead to delayed discharges from hospital which lead to shortages of acute beds, impeded patient flow, crowding in ED and the inability of ambulances to handover patients to ED.
14. Significant average handover delays at RCHT were recorded for every month of 2024. This is a picture reflected across the SW and indeed nationally.
15. The average handover delays conceal spikes such as that which led to the long delay in this case. Such long delays increase the risk of mortality.
16. There are continuing delays of patients from ED which is evidenced by the ongoing failure to regularly meet the 4-hour standard. These delays increase the risk of mortality.
17. Over the last year up to 16% of patients in RCHT have been of external NCTR status, patients who meet the criteria for discharge but cannot be discharged for reasons external to RCHT.
18. The court found that if the external NCTR numbers could be reduced, this would significantly address current issues of ambulance delays, ED crowding, and the shortage of acute beds.
19. The main drivers of external NCTR patients are inadequate social care provision, community hospital provision and primary healthcare support on discharge.
20. The court noted the SWAST systems report which found… ‘’….there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.’’
21. Approximately 10% of social care posts in Cornwall are currently vacant notwithstanding Cornwall Council securing the agreement of social care providers to pay the living wage. This reflects the national picture of 165,000 vacant social care posts.
22. The extent of the obligation on local authorities is set out in the Care Act s5 A local authority must promote the efficient and effective operation of a market in services for meeting care and support needs with a view to ensuring [inter alia] …. a variety of high quality services to choose from…
23. The NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market.
24. The organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision, primary healthcare provision and community hospital provision. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
25. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm. Information Classification: PUBLIC
Inquest Conclusion
Kevin died from an undiagnosed and possibly treatable heart condition, following an ambulance delay attributable to a systemic failure related to the whole system of health and social care. The ambulance delay was possibly causative of death in that it denied Kevin potentially lifesaving treatment.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.