Andrew Collins
PFD Report
All Responded
Ref: 2018-0336
All 1 response received
· Deadline: 27 Nov 2018
Response Status
Responses
1 of 1
56-Day Deadline
27 Nov 2018
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
In the circumstances it is my statutory duty t0 report to you: [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was a of some 3 hours in sending an ambulance t0 Mr Collins when it was clear that his clinical picture was rapidly deteriorating May: delay
The first 999 call was received at 16.10 on the 6ih June and correctly categorised but no vehicle was available to be dispatched to assist him: further 999 call was made by his partner at 18.09 and again at 18.55 at which point he was described as "just about breathing and just about conscious" An ambulance became available and was on scene at 19.10. He was conveyed to the University Hospital of Wales at 20.08 and handed over to hospital staff at 20.26. Whilst the evidence suggested that the calls to the ambulance service were correctly categorised as having urgent clinical priority a clear lack of resources meant that there was a significant delay in attending t0 a critically unwell and deteriorating patient which, in my opinion must create a risk that further deaths may occur:
The first 999 call was received at 16.10 on the 6ih June and correctly categorised but no vehicle was available to be dispatched to assist him: further 999 call was made by his partner at 18.09 and again at 18.55 at which point he was described as "just about breathing and just about conscious" An ambulance became available and was on scene at 19.10. He was conveyed to the University Hospital of Wales at 20.08 and handed over to hospital staff at 20.26. Whilst the evidence suggested that the calls to the ambulance service were correctly categorised as having urgent clinical priority a clear lack of resources meant that there was a significant delay in attending t0 a critically unwell and deteriorating patient which, in my opinion must create a risk that further deaths may occur:
Responses
Response received
View full response
Dear Mr Barkley Re: Regulation 28 relating to Inquest of Andrew Collins am writing in response to the Regulation 28 Report; to Prevent Future Deaths Issued to the Welsh Ambulance Services NHS Trust (the Trust) on 2 October 2018. This was issued following the conclusion of the inquest for Mr Andrew Collins: The Trust acknowledges your concers regarding our lack of resourcing; which meant thal there was a significant delay in attending to a critically unwell patient: The supporting information accompanying this letter, highlights the strategic and operational quality improvements in patient safety that have been completed or are underway: These are aimed at alleviating harm by improving our available resources to respond t0 patients within our communities. Continuous improvements are ongoing with our Health Board colleagues and we are working collaboratively t progress safety, effectiveness and a positive experience for patients and their carers The initiatives that the Trust are continuing t0 working on, to deliver and enable an improved resourcing picture include, the following; That planned resources are sufficient to meet overall demand That we align production against demand by local and time of That we reduce sickness absence That we reduce handover t0 clear duration Codand Dres Docher (Imerkn} Marn Wocdhrd Prt WetthedMICh { Enautwve Kllont "Dott Yadnodaitt N Cidutli [o1obuod My Gymnro Iut 5403mo Te Tnual wetonas Cotetnondun h Wiueh Enghh key day
That We Introduce safe alteratives to responding to scene where this is appropriate That we reduce conveyance where safe and appropriate and provide care in the patlents home utllising advanced practitioners The accompanying action plan will provlde you with the detail of this work, in addition to other quality improvement initiatives designed to safely release resources to respond t0 patients in greatest need. This includes the introduction of Falls Framework and increasing scope of practice for our Community First Responders. In addilion to the actions contained within the attached plan, the Trust has undertaken and completed a robust review of the "Explorer Project" _ The aim of this was the Introduction of "ring fencing" to stabilise resource capacity In the Cwm Taf area and to prevent the migration of emergency resources into busier adjacent Health Board areas. The Explorer Project was a joint programme of work between the Trust and the Cwm Taf University Health Board (CTUHB) designed to improve ambulance response times in the Cwm Taf area of Wales. would Ilike to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board, continue to work in collaboration t0 drive the improvements forward. We continue to strengthen the out of hospital alternative pathways to improve efficiency and effectiveness of care for our patlents and make best use of our resources_ We hope that we have been able to assure you that we remain focused t0 improve our services together and that actions taken to date have had an Impact in relation t0 all of the areas identified within thls Regulation 28 Report: would Iike to extend the offer t0 meet with you to discuss our response In more detail and to provide you with assurance of our commitment to the continuous improvement our service provision:
That We Introduce safe alteratives to responding to scene where this is appropriate That we reduce conveyance where safe and appropriate and provide care in the patlents home utllising advanced practitioners The accompanying action plan will provlde you with the detail of this work, in addition to other quality improvement initiatives designed to safely release resources to respond t0 patients in greatest need. This includes the introduction of Falls Framework and increasing scope of practice for our Community First Responders. In addilion to the actions contained within the attached plan, the Trust has undertaken and completed a robust review of the "Explorer Project" _ The aim of this was the Introduction of "ring fencing" to stabilise resource capacity In the Cwm Taf area and to prevent the migration of emergency resources into busier adjacent Health Board areas. The Explorer Project was a joint programme of work between the Trust and the Cwm Taf University Health Board (CTUHB) designed to improve ambulance response times in the Cwm Taf area of Wales. would Ilike to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board, continue to work in collaboration t0 drive the improvements forward. We continue to strengthen the out of hospital alternative pathways to improve efficiency and effectiveness of care for our patlents and make best use of our resources_ We hope that we have been able to assure you that we remain focused t0 improve our services together and that actions taken to date have had an Impact in relation t0 all of the areas identified within thls Regulation 28 Report: would Iike to extend the offer t0 meet with you to discuss our response In more detail and to provide you with assurance of our commitment to the continuous improvement our service provision:
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action.
Report Sections
Investigation and Inquest
On the 25th June 2018 | commenced an investigation into the death of Andrew Collins_ The investigation concluded at the end ofan inquest on the 26th September 2018. The conclusion from the inquest was that of Natural Causes".
Circumstances of the Death
On the 6ih June 2018 the deceased became acutely unwell at his home address with a sudden onset of severe headache He deteriorated rapidly and became unconscious: On admission to the University Hospital of Wales in Cardiff scanning revealed a subdural haematoma_ He underwent emergency neurosurgery t0 evacuate the haematoma, never recovered and passed away on the 16ih June_ He was on life time anticoagulation for atrial fibrillation. He was anticoagulated with warfarin: It was alleged that he was subject to an assault in which he was struck t0 the head with a bar On Or around the 27th The evidence both from clinician and pathologist failed to make a link between the assault and the bleed. The evidence indicated that the bleed was far more recent and likely to have commenced seventy two hours before his admission to hospital on the 6th June
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.