Gina Bywater
PFD Report
All Responded
Ref: 2023-0435
All 1 response received
· Deadline: 2 Jan 2024
Response Status
Responses
1 of 1
56-Day Deadline
2 Jan 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
Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region. These periods of non-availability (in this case nearly 10 hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself. Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Gina’s each year, identified that had an ambulance for Gina arrived within the target time, the drugs she could have been given by ambulance personnel, and her early transport to hospital, would on a balance of probabilities have saved her life. I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life.
Responses
The Department of Health and Social Care outlines significant funding provisions for ambulance services and hospital discharge, alongside NHS England's implementation of a new performance improvement approach. It details the East of England Ambulance Service's ongoing operational plan, which includes recruitment, increased clinical triage, and the establishment of an Unscheduled Care Coordination Hub.
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Dear Mr Parsley,
Thank you for your letter of 7 November 2023 to the Secretary of State for Health and Social Care regarding the death of Gina Bywater. I am replying as Minister with responsibility for urgent and emergency services. Please accept my sincere apologies for the 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 deeply sorry I was to read the circumstances of Ms Bywater’s death and I offer my sincere condolences to her family. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention.
In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE advise that EEAST is implementing an operational performance and improvement plan locally to improve efficiency and maximise ambulance availability. This includes recruitment to increase the number of frontline clinicians, and also to increase the clinical triage of calls to identify patients that can be appropriately transferred to alternative services, including for Category 2 incidents where the severity of conditions can vary substantially. This helps to free up frontline resource to respond more quickly to those who need an ambulance response most urgently. This has also been supported by the establishment of an Unscheduled Care Coordination Hub.
As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing and the impact of waiting times for patients. In January 2023, NHS England published a two year 'Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, with a target for this year to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at:
recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-2024.pdf
Your report highlights that EEAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.
£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.
NHS England also implemented a new tiering performance and improvement approach to support challenged ambulance trusts and wider systems. There is support in place at national and regional level to support Tiers 1 and 2 with EEAST in Tier 2 with a universal improvement support offer being made available for all systems.
Since publication of the recovery plan in January 2023, there have been improvements in performance. Nationally 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 over 27%. In the East of England, average Category 2 response times were over 23 minutes faster over the same time period, a 34% reduction. There have also been improvements in handover delays with average EEAST handover times 30 minutes 57 seconds in May 2024, almost 14 minutes faster than October
2023.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Thank you for your letter of 7 November 2023 to the Secretary of State for Health and Social Care regarding the death of Gina Bywater. I am replying as Minister with responsibility for urgent and emergency services. Please accept my sincere apologies for the 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 deeply sorry I was to read the circumstances of Ms Bywater’s death and I offer my sincere condolences to her family. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention.
In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE advise that EEAST is implementing an operational performance and improvement plan locally to improve efficiency and maximise ambulance availability. This includes recruitment to increase the number of frontline clinicians, and also to increase the clinical triage of calls to identify patients that can be appropriately transferred to alternative services, including for Category 2 incidents where the severity of conditions can vary substantially. This helps to free up frontline resource to respond more quickly to those who need an ambulance response most urgently. This has also been supported by the establishment of an Unscheduled Care Coordination Hub.
As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing and the impact of waiting times for patients. In January 2023, NHS England published a two year 'Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, with a target for this year to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at:
recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-2024.pdf
Your report highlights that EEAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.
£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.
NHS England also implemented a new tiering performance and improvement approach to support challenged ambulance trusts and wider systems. There is support in place at national and regional level to support Tiers 1 and 2 with EEAST in Tier 2 with a universal improvement support offer being made available for all systems.
Since publication of the recovery plan in January 2023, there have been improvements in performance. Nationally 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 over 27%. In the East of England, average Category 2 response times were over 23 minutes faster over the same time period, a 34% reduction. There have also been improvements in handover delays with average EEAST handover times 30 minutes 57 seconds in May 2024, almost 14 minutes faster than October
2023.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Report Sections
Investigation and Inquest
On 16 December 2022 I commenced an investigation into the death of Gina Marie BYWATER aged 36. The investigation concluded at the end of the inquest on 01 November 2023. The conclusion of the inquest was that: Narrative Conclusion - Natural causes due to an untreated cardiac condition, the death being contributed to by a delay in attendance of an ambulance, that delay being caused by extreme resource pressures on the ambulance service at the time. The medical cause of death was confirmed as: 1a Acute Myocardial Infarction 1b 1c 2 Fatty Liver, Pancreatic Cyst and Fibrosis
Circumstances of the Death
On the 13th December 2022 Gina Bywater was declared deceased at her home address in Suffolk. Gina had become unwell at approximately 22:00 on 12th December 2022, with vomiting and shortness of breath. An ambulance was requested via a 999 call at 00:01 hours on the 13th December 2022, but due to high service demand, and ambulances waiting to off-load their patients at the local hospitals, no ambulance was immediately available. A second 999 call was made at 01:08 stating that Gina was now suffering chest pains, and a third was made at 04:07, but again no resources were available. All of the 999 calls had been coded at Category 2 , with an average expected response time of 40 minutes, and a target attendance time of 18 minutes. The East of England Ambulance service made a welfare call at 09:36, and during this call it was identified that Gina had gone into cardiac arrest. A Category 1 response was therefore initiated and an ambulance arrived with Gina at 09:45. A subsequent post-mortem examination identified that she had died as the result of a heart attack. The delay in an ambulance attending meant that lifesaving treatment could not be given, so that delay directly contributed to Gina’s death.
Copies Sent To
2. East of England Ambulance Service
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.