Peter Beresford
PFD Report
All Responded
Ref: 2024-0138
All 1 response received
· Deadline: 7 May 2024
Response Status
Responses
1 of 1
56-Day Deadline
7 May 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) Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.
(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.
(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.
Responses
Response received
View full response
Dear Ms Costello,
Thank you for your letter of 12 March 2024 to the Secretary of State for Health and Social Care about the death of Peter Beresford. I am replying as Minister with responsibility for urgent and emergency services.
Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Beresford’s death and I offer my sincere condolences to his family. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful to you for bringing these matters to my attention.
You have appropriately shared your report and concerns with NWAS who are best placed to respond on the specific actions being taken locally to improve ambulance response times. I note the measures the trust has said are being taken to improve performance, as set out in your report, including the ongoing recruitment of staff and also that performance regionally has been improving.
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 on average across this 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 NWAS were under high demand at the time of the incident. A primary aim of our delivery 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 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 previous year, a reduction of 27%. NWAS average Category 2 response times were also over 13 minutes faster in 2023-24 compared to the previous year, a 32% reduction.
In March 2024, average patient handover time in the NWAS region was 32 minutes 51 seconds, and the second month in a row that times have improved (information on ambulance handover times has been published since October 2023).
However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Thank you for your letter of 12 March 2024 to the Secretary of State for Health and Social Care about the death of Peter Beresford. I am replying as Minister with responsibility for urgent and emergency services.
Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Beresford’s death and I offer my sincere condolences to his family. It is vital that we learn from incidents, where they are identified, to improve NHS care. I am grateful to you for bringing these matters to my attention.
You have appropriately shared your report and concerns with NWAS who are best placed to respond on the specific actions being taken locally to improve ambulance response times. I note the measures the trust has said are being taken to improve performance, as set out in your report, including the ongoing recruitment of staff and also that performance regionally has been improving.
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 on average across this 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 NWAS were under high demand at the time of the incident. A primary aim of our delivery 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 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 previous year, a reduction of 27%. NWAS average Category 2 response times were also over 13 minutes faster in 2023-24 compared to the previous year, a 32% reduction.
In March 2024, average patient handover time in the NWAS region was 32 minutes 51 seconds, and the second month in a row that times have improved (information on ambulance handover times has been published since October 2023).
However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Report Sections
Investigation and Inquest
On 23rd October 2023 I commenced an investigation into the death of Peter Beresford, then aged 65 years. The investigation concluded at the end of the inquest on 23rd February 2024. The conclusion of the inquest was a narrative conclusion that Mr Beresford died as a result of acute myocardial ischaemia precipitated by coronary thrombosis as a consequence of atherosclerosis against a background of high blood pressure and high cholesterol. The medical cause of death being: 1 (a) Acute myocardial ischaemia (b) Coronary thrombosis (c) Coronary atherosclerosis
Circumstances of the Death
Peter Beresford suffered from high cholesterol and high blood pressure which both increase the risk of ischaemic heart disease. On 25th September 2023, Mr Beresford contacted the North West Ambulance Service complaining of chest pain at 05:38. His call was prioritised appropriately as a Category 2 call. When an ambulance arrived at his home address at 07:14 he was already deceased. The average response standard for Category 2 calls is within 18 minutes and attendance is within 40 minutes nine out of ten times. A post-mortem examination revealed that Mr Beresford died as a result of acute myocardial ischaemia precipitated by coronary thrombosis as a consequence of coronary atherosclerosis. The Inquest heard that the North West Ambulance Service was unable to meet average response standards due to resourcing levels and the fact that ambulances were unable to clear the region’s hospitals because of the long waiting times there. A level 2 incident plan was commenced as a result. A number of measures have been undertaken by the North West Ambulance Service to address emergency response times including: Ongoing recruitment, The introduction of a Clinical assessment of category 3 cases rather than automatic ambulance allocation, Introduction of Hospital Ambulance Liaison Offers to assist ambulances to clear hospitals and reduce waiting time. The inquest heard that waiting times across the North West region are still impacted by peaks in demand and problems clearing the regions hospitals despite the above measures.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.