Charles Devos
PFD Report
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Ref: 2024-0680
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· Deadline: 4 Feb 2025
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4 Feb 2025
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) Extreme operational pressure on ambulance services leading to volumes of unallocated 999 calls and excessive ambulance delays. There is a direct connection between the extreme operational pressure on SWAST and inadequate social and community care provision. This is because the inadequacy in these services creates a risk of future systemic failures causing excessive volumes of unallocated 999 calls and ambulance delays.
(2) Ambulance call handlers and clinical advisors are being forced to resort to extreme mitigating measures to try and manage risks created by the systemic failures. These measures are being relied on in circumstances where ordinarily an emergency ambulance would be provided. The mitigating measures include resorting to recommending self-conveyance, arranging taxis and unattended drop offs at ED.
(2) Ambulance call handlers and clinical advisors are being forced to resort to extreme mitigating measures to try and manage risks created by the systemic failures. These measures are being relied on in circumstances where ordinarily an emergency ambulance would be provided. The mitigating measures include resorting to recommending self-conveyance, arranging taxis and unattended drop offs at ED.
Responses
DHSC acknowledges concerns about ambulance and social care pressures and outlines several national initiatives. These include a £25.6 billion healthcare funding commitment, a 10-Year Health Plan by Spring 2025, and an independent commission into adult social care starting April 2025.
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Dear Mr Davies,
Thank you for the Regulation 28 report of 10 December 2024 sent to the Secretary of State for Health and Social Care about the death of Charles George Edward Devos. 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 Devos’ 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 the operational pressure on the South West Ambulance Service NHS Foundation Trust (SWAST) as a result of systemic issues including those impacting social and community services. 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.
The Cornwall and Isles of Scilly Integrated Care Board (ICB) recognises the continued challenges the area has in relation to ambulance handover delays. Their winter plan for 2024/25, covers three overarching areas to support sustainable improvement:
• Maximising the utilisation of admission avoidance services such as Community Same Day Emergency Care (SDEC), Community Assessment and Treatment Units (CATU) Minor Injury Units, Virtual Wards, right care and x-rays cars. These services are in place to keep people well at home, avoiding ambulance and the Emergency Department demand wherever possible and instead focussing on delivering care for individuals at home or outside of the trust.
• Patient flow improvements have been introduced to ensure that patients get to the right team at the right time without encountering delays. In addition to this, the ICB are committed to making sure patients, their families and carers participate in decisions around their care and safe discharge.
• Working to improve hospital flow by focussing on timely discharges from both the acute trust and local community services. T
In addition, the Cornwall and Isles of Scilly Integrated Care System, single point of access (SPOA) went live in November 2024. This is a collaborative model aimed at combining a number of current functions into a single, multidisciplinary, co-located, 24/7 virtual centre. The SPOA aims to reduce the number of ambulances going to ED by directing to alternative community provision when appropriate and allow the virtual wards to manage a wider cohort of patients with senior clinical cover. Data from 11 November 2024 to 2 January 2025 shows that over 2000 cases have been through the SPOA. Only 25% of these cases resulted in the patient being transferred to the emergency department with the remaining being managed either at home or a community- based service.
At national level, I agree that ambulance response times have been below the high standards that patients should expect in recent years. We are determined to tackle the challenges facing the system, which is why we are taking a systemic approach through our Plan for Change to rebuild the health service.
The Government will always be honest about the challenges facing the NHS and, although we are committed to returning ambulance response times to the safe operational standards set out in the NHS Constitution, we must be clear that there are no quick fixes.
However, we are determined to turn things around through providing investment and implementing reforms. That is why the Chancellor announced £25.6 billion of additional healthcare funding over the next two years covering 2024-2026. In Spring 2025, to accompany this additional investment the Government will publish its 10-Year Health Plan, that will set out the radical reforms for the NHS so it can tackle the problems of today and tomorrow.
The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing for the future. In the shorter-term, by this Spring we will also set out the lessons learned from this winter and the improvements that we will put in place to improve urgent and emergency care ahead of next winter. Turning to the concerns raised about social care, the Government is launching an independent commission into adult social care as part of our critical first steps towards delivering a National Care Service. The Commission, which is expected to begin in April
2025, will form a key part of the government’s Plan for Change, recognising the importance of adult social care in its own right, as well as its role in supporting the NHS. It is a once in a generation opportunity to transcend party politics and engage in genuine debate on how we can deliver a National Care Service, ensuring all voices are heard and putting the voices of those with lived experience at the heart of the conversation. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 10 December 2024 sent to the Secretary of State for Health and Social Care about the death of Charles George Edward Devos. 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 Devos’ 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 the operational pressure on the South West Ambulance Service NHS Foundation Trust (SWAST) as a result of systemic issues including those impacting social and community services. 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.
The Cornwall and Isles of Scilly Integrated Care Board (ICB) recognises the continued challenges the area has in relation to ambulance handover delays. Their winter plan for 2024/25, covers three overarching areas to support sustainable improvement:
• Maximising the utilisation of admission avoidance services such as Community Same Day Emergency Care (SDEC), Community Assessment and Treatment Units (CATU) Minor Injury Units, Virtual Wards, right care and x-rays cars. These services are in place to keep people well at home, avoiding ambulance and the Emergency Department demand wherever possible and instead focussing on delivering care for individuals at home or outside of the trust.
• Patient flow improvements have been introduced to ensure that patients get to the right team at the right time without encountering delays. In addition to this, the ICB are committed to making sure patients, their families and carers participate in decisions around their care and safe discharge.
• Working to improve hospital flow by focussing on timely discharges from both the acute trust and local community services. T
In addition, the Cornwall and Isles of Scilly Integrated Care System, single point of access (SPOA) went live in November 2024. This is a collaborative model aimed at combining a number of current functions into a single, multidisciplinary, co-located, 24/7 virtual centre. The SPOA aims to reduce the number of ambulances going to ED by directing to alternative community provision when appropriate and allow the virtual wards to manage a wider cohort of patients with senior clinical cover. Data from 11 November 2024 to 2 January 2025 shows that over 2000 cases have been through the SPOA. Only 25% of these cases resulted in the patient being transferred to the emergency department with the remaining being managed either at home or a community- based service.
At national level, I agree that ambulance response times have been below the high standards that patients should expect in recent years. We are determined to tackle the challenges facing the system, which is why we are taking a systemic approach through our Plan for Change to rebuild the health service.
The Government will always be honest about the challenges facing the NHS and, although we are committed to returning ambulance response times to the safe operational standards set out in the NHS Constitution, we must be clear that there are no quick fixes.
However, we are determined to turn things around through providing investment and implementing reforms. That is why the Chancellor announced £25.6 billion of additional healthcare funding over the next two years covering 2024-2026. In Spring 2025, to accompany this additional investment the Government will publish its 10-Year Health Plan, that will set out the radical reforms for the NHS so it can tackle the problems of today and tomorrow.
The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing for the future. In the shorter-term, by this Spring we will also set out the lessons learned from this winter and the improvements that we will put in place to improve urgent and emergency care ahead of next winter. Turning to the concerns raised about social care, the Government is launching an independent commission into adult social care as part of our critical first steps towards delivering a National Care Service. The Commission, which is expected to begin in April
2025, will form a key part of the government’s Plan for Change, recognising the importance of adult social care in its own right, as well as its role in supporting the NHS. It is a once in a generation opportunity to transcend party politics and engage in genuine debate on how we can deliver a National Care Service, ensuring all voices are heard and putting the voices of those with lived experience at the heart of the conversation. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Report Sections
Investigation and Inquest
On 20 July 2023 an investigation was commenced into the death of 54-year-old Charles George Edward Devos. The investigation concluded at the end of the inquest on 2 December 2024.
The medical cause of death was found as follows:
1a) Small bowel infarction
The four statutory questions - who, when, where and how – were answered as follows:
Charles George Edward Devos died on 9 January 2021 at Trevarthian Farmhouse Plain-an-Gwarry Marazion Cornwall from an acute bowel condition. Charles’ death followed 999 calls by Charles’ family at 22:55 hours and 23:47 hours on 8 January 2021 requesting an ambulance. There was a delay in South West Ambulance Service (SWAST) conducting a necessary clinical assessment to determine categorisation of priority. This delay denied Charles an opportunity to obtain potentially lifesaving Information Classification: PUBLIC treatment at hospital. Charles died at home on 9 January 2021 shortly after the arrival of paramedics. This missed opportunity is attributable to the extreme operational pressures exerted upon SWAST which was a direct result of the failure of the whole system of health and social care which adversely influenced or delayed decisions made by SWAST.
The conclusion of the inquest was as follows:
Charles died from a treatable bowel condition following a missed opportunity to obtain potentially lifesaving treatment. This opportunity was missed due to extreme operational pressure on ambulance services following the failure of the system of health and social care which was possibly causative of Charles’ death.
The medical cause of death was found as follows:
1a) Small bowel infarction
The four statutory questions - who, when, where and how – were answered as follows:
Charles George Edward Devos died on 9 January 2021 at Trevarthian Farmhouse Plain-an-Gwarry Marazion Cornwall from an acute bowel condition. Charles’ death followed 999 calls by Charles’ family at 22:55 hours and 23:47 hours on 8 January 2021 requesting an ambulance. There was a delay in South West Ambulance Service (SWAST) conducting a necessary clinical assessment to determine categorisation of priority. This delay denied Charles an opportunity to obtain potentially lifesaving Information Classification: PUBLIC treatment at hospital. Charles died at home on 9 January 2021 shortly after the arrival of paramedics. This missed opportunity is attributable to the extreme operational pressures exerted upon SWAST which was a direct result of the failure of the whole system of health and social care which adversely influenced or delayed decisions made by SWAST.
The conclusion of the inquest was as follows:
Charles died from a treatable bowel condition following a missed opportunity to obtain potentially lifesaving treatment. This opportunity was missed due to extreme operational pressure on ambulance services following the failure of the system of health and social care which was possibly causative of Charles’ death.
Circumstances of the Death
1. Charles’ family called 999 on 8th January 2021 at 22:55 hours requesting an emergency ambulance. Charles was reported to have vomited and was sweating in a hot and cold fever, and in dreadful abdominal pain. The call was referred for clinical assessment in order to determine categorisation of priority.
2. There was a further 999 call at 23:47 from Charles’ family due to the severity of his symptoms.
3. There was a conversation between call handler and a clinical adviser about whether to upgrade the call for an emergency ambulance. The clinical advisor was informed that Charles was reported to have vomited and to be rolling around in pain and that Charles could be heard by the call handler to be screaming in agony.
4. The clinician decided the appropriate course of action was for clinical triage. Due to severe operational pressure the clinician did not have time to conduct clinical assessment herself at that time. The 999 call was again referred for clinical assessment in order to determine categorisation of priority.
5. Clinical assessment was further delayed until a call back by a clinician at 03:15 hours on 9 January 2021.
6. The court found that the reported symptoms at 23:47 likely necessitated the prioritization of Charles’ clinical triage which should have taken place at 23:47 or shortly thereafter.
7. If triage had taken place at 23:47 or shortly thereafter it is possible that triage would have led to an emergency ambulance being arranged. This is because triage would have been taking place at a time when Charles was still suffering the initial symptoms of acute bowel ischemia.
8. If an emergency ambulance had collected Charles in the early hours of 9 January, it is probable that he would have received lifesaving treatment. The sooner that he could have been taken to hospital for surgery the likelier it is that he would have survived.
9. The court found that the delay in clinical assessment amounted to a missed opportunity to provide potentially curative surgery.
10. By the time of the clinician call back at 0315, Charles’ condition had worsened but the presentation had altered so that it appeared to have improved. On the false belief of improvement Charles agreed to self-convey to hospital but did not do so.
11. By the time Charles’ family called again for an ambulance on the afternoon of 9 January it was too late. His condition had deteriorated to such an extent that it was not survivable.
12. Charles died at home shortly after the arrival of paramedics.
SYSTEMIC FAILURE IN 2021
13. The court heard that on 8th January 2021 the ambulance service lost 109 hours of ambulance availability to handover delays at Royal Cornwall Hospital (RCHT). This excludes the 15-minute allowance for each handover. That is the equivalent to losing ten, 12-hour Information Classification: PUBLIC ambulance shifts. This led to significant delays in ambulance response times due to the numbers of ambulances detained at hospital.
14. As a consequence of handover delays there was a significant volume of unallocated emergency calls to the ambulance service, awaiting ambulances, triage or assessments.
15. The court found that severe and extreme operational pressure on SWAST influenced or delayed necessary decisions.
16. Reports from SWAST and the Health Services Safety Investigation Body (HSSIB) found a strong correlation between handover delays and ambulance response delays.
17. The SWAST report stated: The investigation found that 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.
18. The reports indicated a direct connection between ambulance delays and inadequate social and community care. 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 emergency departments (ED) and the inability of ambulances to handover patients to ED.
19. There was no culpability on the part of SWAST call handlers or clinicians who were doing their best to mitigate the risks created by the systemic failure.
20. 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 and community care provision. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
21. 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.
22. The court found that the extreme and severe pressure on SWAST can be attributed to by a systemic failure of the entire system of health and social care.
SYSTEMIC FAILURES IN 2024
23. Significant average handover delays at RCHT were recorded for every month of 2024 up the date of Inquest.
24. SWAST witnesses stated that the average handover delays conceal spikes which exert severe operational pressure. Such long delays increase the risk of mortality.
25. The court heard evidence of extreme mitigating measures being deployed by SWAST and other ambulance services across England and Wales seeking to reduce risks following ambulance delays. The court discussed the hypothetical example of a patient with a suspected heart attack facing a long ambulance delay. The court heard that due to the risks associated with ambulance delays a number of mitigating measures would be pursued in circumstances where ordinarily an emergency ambulance would be provided. These included:
• Self-conveyance: recommending that the patient arrange for family or friends to convey them to hospital with safety netting advice if the condition worsens (namely pull over and call 999).
• Taxis: Arranging taxis to collect said patients if family or friends cannot assist.
• Unattended drop offs: Ambulance paramedics wheeling patients into emergency departments on spare ambulance beds notwithstanding there being no available bed for that patient in ED, and leaving the patient unattended by ambulance crews, in order to release ambulances to attend to other calls. Information Classification: PUBLIC
2. There was a further 999 call at 23:47 from Charles’ family due to the severity of his symptoms.
3. There was a conversation between call handler and a clinical adviser about whether to upgrade the call for an emergency ambulance. The clinical advisor was informed that Charles was reported to have vomited and to be rolling around in pain and that Charles could be heard by the call handler to be screaming in agony.
4. The clinician decided the appropriate course of action was for clinical triage. Due to severe operational pressure the clinician did not have time to conduct clinical assessment herself at that time. The 999 call was again referred for clinical assessment in order to determine categorisation of priority.
5. Clinical assessment was further delayed until a call back by a clinician at 03:15 hours on 9 January 2021.
6. The court found that the reported symptoms at 23:47 likely necessitated the prioritization of Charles’ clinical triage which should have taken place at 23:47 or shortly thereafter.
7. If triage had taken place at 23:47 or shortly thereafter it is possible that triage would have led to an emergency ambulance being arranged. This is because triage would have been taking place at a time when Charles was still suffering the initial symptoms of acute bowel ischemia.
8. If an emergency ambulance had collected Charles in the early hours of 9 January, it is probable that he would have received lifesaving treatment. The sooner that he could have been taken to hospital for surgery the likelier it is that he would have survived.
9. The court found that the delay in clinical assessment amounted to a missed opportunity to provide potentially curative surgery.
10. By the time of the clinician call back at 0315, Charles’ condition had worsened but the presentation had altered so that it appeared to have improved. On the false belief of improvement Charles agreed to self-convey to hospital but did not do so.
11. By the time Charles’ family called again for an ambulance on the afternoon of 9 January it was too late. His condition had deteriorated to such an extent that it was not survivable.
12. Charles died at home shortly after the arrival of paramedics.
SYSTEMIC FAILURE IN 2021
13. The court heard that on 8th January 2021 the ambulance service lost 109 hours of ambulance availability to handover delays at Royal Cornwall Hospital (RCHT). This excludes the 15-minute allowance for each handover. That is the equivalent to losing ten, 12-hour Information Classification: PUBLIC ambulance shifts. This led to significant delays in ambulance response times due to the numbers of ambulances detained at hospital.
14. As a consequence of handover delays there was a significant volume of unallocated emergency calls to the ambulance service, awaiting ambulances, triage or assessments.
15. The court found that severe and extreme operational pressure on SWAST influenced or delayed necessary decisions.
16. Reports from SWAST and the Health Services Safety Investigation Body (HSSIB) found a strong correlation between handover delays and ambulance response delays.
17. The SWAST report stated: The investigation found that 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.
18. The reports indicated a direct connection between ambulance delays and inadequate social and community care. 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 emergency departments (ED) and the inability of ambulances to handover patients to ED.
19. There was no culpability on the part of SWAST call handlers or clinicians who were doing their best to mitigate the risks created by the systemic failure.
20. 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 and community care provision. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
21. 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.
22. The court found that the extreme and severe pressure on SWAST can be attributed to by a systemic failure of the entire system of health and social care.
SYSTEMIC FAILURES IN 2024
23. Significant average handover delays at RCHT were recorded for every month of 2024 up the date of Inquest.
24. SWAST witnesses stated that the average handover delays conceal spikes which exert severe operational pressure. Such long delays increase the risk of mortality.
25. The court heard evidence of extreme mitigating measures being deployed by SWAST and other ambulance services across England and Wales seeking to reduce risks following ambulance delays. The court discussed the hypothetical example of a patient with a suspected heart attack facing a long ambulance delay. The court heard that due to the risks associated with ambulance delays a number of mitigating measures would be pursued in circumstances where ordinarily an emergency ambulance would be provided. These included:
• Self-conveyance: recommending that the patient arrange for family or friends to convey them to hospital with safety netting advice if the condition worsens (namely pull over and call 999).
• Taxis: Arranging taxis to collect said patients if family or friends cannot assist.
• Unattended drop offs: Ambulance paramedics wheeling patients into emergency departments on spare ambulance beds notwithstanding there being no available bed for that patient in ED, and leaving the patient unattended by ambulance crews, in order to release ambulances to attend to other calls. Information Classification: PUBLIC
Inquest Conclusion
Charles died from a treatable bowel condition following a missed opportunity to obtain potentially lifesaving treatment. This opportunity was missed due to extreme operational pressure on ambulance services following the failure of the system of health and social care which was possibly causative of Charles’ death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.