Derek Shaw
PFD Report
All Responded
Ref: 2022-0370
All 1 response received
· Deadline: 6 Jan 2023
Response Status
Responses
1 of 1
56-Day Deadline
6 Jan 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
(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves.
(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves.
Responses
The Department of Health and Social Care acknowledged concerns about ambulance delays and capacity, outlining its 'Delivery plan for recovering urgent and emergency care services'. This plan involves £200 million in additional funding to boost ambulance capacity, introduce new vehicles, and has already led to significant improvements in national and East of England ambulance response times.
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Dear Mrs Wood,
Thank you for your Regulation 28 report to prevent future deaths dated 11 November 2022 about the death of Derek Shaw. I am replying as the Minister with responsibility for Urgent and Emergency Care. 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 deeply sorry I was to read the circumstances of Mr Shaw’s death and I offer my sincere condolences to his family. I am grateful to you for bringing these matters to my attention.
The report raises concerns about ambulance capacity and response times by East of England Ambulance Service NHS Trust (EEAST). In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). I have been informed that the CQC carried out routine engagement with the Trust to review progress against its action plan and to ensure they comply with CQC regulations. More generally, I have been assured that the CQC will continue to have regular meetings with the NHS trusts locally to monitor risks and follow up on Prevention of Future Death reports.
As the Minister responsible for urgent and emergency case 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
Your report highlights that EEAST 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.
At a national level, we have seen significant improvements in performance this year compared to last year. In winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a reduction of nearly 25%. EEAST average Category 2 response times were over 23 minutes faster compared to the same time period last year, a 32% reduction.
However, I recognise there is still more to do to reduce response times down further and back towards pre-pandemic levels – and this is the action we will continue to be taking as part of the government’s commitment to improving NHS services and reducing waiting times.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Thank you for your Regulation 28 report to prevent future deaths dated 11 November 2022 about the death of Derek Shaw. I am replying as the Minister with responsibility for Urgent and Emergency Care. 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 deeply sorry I was to read the circumstances of Mr Shaw’s death and I offer my sincere condolences to his family. I am grateful to you for bringing these matters to my attention.
The report raises concerns about ambulance capacity and response times by East of England Ambulance Service NHS Trust (EEAST). In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). I have been informed that the CQC carried out routine engagement with the Trust to review progress against its action plan and to ensure they comply with CQC regulations. More generally, I have been assured that the CQC will continue to have regular meetings with the NHS trusts locally to monitor risks and follow up on Prevention of Future Death reports.
As the Minister responsible for urgent and emergency case 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
Your report highlights that EEAST 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.
At a national level, we have seen significant improvements in performance this year compared to last year. In winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a reduction of nearly 25%. EEAST average Category 2 response times were over 23 minutes faster compared to the same time period last year, a 32% reduction.
However, I recognise there is still more to do to reduce response times down further and back towards pre-pandemic levels – and this is the action we will continue to be taking as part of the government’s commitment to improving NHS services and reducing waiting times.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Report Sections
Investigation and Inquest
On the 25th May 2022 an inquest was opened into the death of Derek Shaw. At the inquest hearing on 11th November 2022 I concluded with a narrative conclusion “He died as a consequence of a soft tissue haemorrhage into his anterior abdominal wall following a fall, contributed to be a delay in an ambulance being available to attend to him.”
Circumstances of the Death
(1) Derek Shaw fell at home on the 21st December and the following morning became unwell. He called an ambulance at 12.52 and the ambulance call was classified as a category 3 call meaning the target time to reach him was 120 minutes.
(2) Capacity meant that no ambulance could be dispatched and whilst one was initially dispatched at 15.46 this ambulance was diverted to a higher priority call. He deteriorated and the ambulance service were contacted again and the category of his call upgraded at 16.46 when he was still conscious.
(3) By the time the ambulance crew arrived at 17.12, he had suffered a cardiac arrest and attempts at resuscitation were unsuccessful.
(4) A post mortem examination revealed that he had died as a consequence of a soft tissue haemorrhage into his anterior abdominal wall as a consequence of the fall. The Pathologist gave evidence that this was an unusual cause of death and earlier intervention would have meant it likely Mr. Shaw would have survived.
(5) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps could be taken by them to Prevent Future Deaths as they had already put steps in place in so far as they were able.
(2) Capacity meant that no ambulance could be dispatched and whilst one was initially dispatched at 15.46 this ambulance was diverted to a higher priority call. He deteriorated and the ambulance service were contacted again and the category of his call upgraded at 16.46 when he was still conscious.
(3) By the time the ambulance crew arrived at 17.12, he had suffered a cardiac arrest and attempts at resuscitation were unsuccessful.
(4) A post mortem examination revealed that he had died as a consequence of a soft tissue haemorrhage into his anterior abdominal wall as a consequence of the fall. The Pathologist gave evidence that this was an unusual cause of death and earlier intervention would have meant it likely Mr. Shaw would have survived.
(5) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps could be taken by them to Prevent Future Deaths as they had already put steps in place in so far as they were able.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.