John Codd
PFD Report
All Responded
Ref: 2024-0415
All 1 response received
· Deadline: 23 Sep 2024
Coroner's Concerns (AI summary)
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.
View full coroner's concerns
1) At the time of these events, (January 2024) monthly crowding analysis, that is the total amount of time patients spent waiting for beds or transport after a decision ‘ready to discharge’ from ED was made totalled 23,875 hours, the equivalent of closing 32 cubicles to ED for 24 hours/day for a whole month.
2) Last month, in June 2024, the situation had improved but still totalled 16,245 hours of lost time, the equivalent of closing 22 cubicles for an entire month.
was clear in his evidence that significant pressures remained on the ED at Royal Cornwall Hospital which had the potential to affect future patient care.
2) Last month, in June 2024, the situation had improved but still totalled 16,245 hours of lost time, the equivalent of closing 22 cubicles for an entire month.
was clear in his evidence that significant pressures remained on the ED at Royal Cornwall Hospital which had the potential to affect future patient care.
Responses
Action Planned
Royal Cornwall Hospitals NHS Trust is implementing changes to improve patient flow including a Clinical Decision Unit, resetting the Same Day Medical Assessment Unit, ensuring medical discharges by 19:00, and identifying a space for a discharge lounge. A system clinical leaders event focused on community alternatives to improve urgent care access. (AI summary)
Royal Cornwall Hospitals NHS Trust is implementing changes to improve patient flow including a Clinical Decision Unit, resetting the Same Day Medical Assessment Unit, ensuring medical discharges by 19:00, and identifying a space for a discharge lounge. A system clinical leaders event focused on community alternatives to improve urgent care access. (AI summary)
View full response
Dear Mr Cox,
Thank you for the Regulation 28 report of 29 July 2024 sent to the Secretary of State for Health and Social Care about the death of Colonel John Frederick Codd. 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 Colonel Codd’s 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. Please accept my sincere apologies for the delay in responding to this matter.
The report raises concerns of poor emergency department performance due to patient flow and discharge issues at Royal Cornwall Hospitals NHS Trust (RCHT). I do 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 RCHT is implementing urgent changes to improve patient flow and care through the emergency department. Priority actions include:
• Making space for a Clinical Decision Unit model, for patients who need more clinical care but don’t need to be admitted to hospital.
• Resetting the footprint occupied by Same Day Medical Assessment Unit (SDMA) and the Discharge Lounge.
• Converting SDMA to a Same Day Emergency Care (SDEC) and having a triage process to ensure only patients considered as same day go to the SDEC.
• Ensuring all medical discharges are completed by 19:00.
• Identifying a space on the Royal Cornwall Hospital site for acute GPs to return to site.
• Making two bays on Acute Medical Unit (AMU) admissions bays.
• Supporting the move of acute medical resource from the emergency department to AMU with the intention of improving short stay performance on AMU.
• Intention to stop the use of Boarding, where patients are sent from an admitting area to a receiving ward prior to a bed being available.
Urgent care improvements include expanding services at West Cornwall Hospital and engaging stakeholders to improve community care alternatives. The trust is also learning from best practice in other hospitals across the country, and the Emergency Care Intensive Support Team are supporting the trust with bringing peer support with clinicians from other trusts to help increase the speed of delivery of their models.
The overall urgent care position in the region is supported by ongoing system actions, including a system clinical leaders event in August which focussed on clinically led plans to maximise community alternatives and update models to improve the urgent care access standards for Cornwall. The Chief Operating Officer at RCHT reports weekly on improvement actions being taken.
At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
Regarding the concern raised about discharge delays, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 29 July 2024 sent to the Secretary of State for Health and Social Care about the death of Colonel John Frederick Codd. 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 Colonel Codd’s 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. Please accept my sincere apologies for the delay in responding to this matter.
The report raises concerns of poor emergency department performance due to patient flow and discharge issues at Royal Cornwall Hospitals NHS Trust (RCHT). I do 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 RCHT is implementing urgent changes to improve patient flow and care through the emergency department. Priority actions include:
• Making space for a Clinical Decision Unit model, for patients who need more clinical care but don’t need to be admitted to hospital.
• Resetting the footprint occupied by Same Day Medical Assessment Unit (SDMA) and the Discharge Lounge.
• Converting SDMA to a Same Day Emergency Care (SDEC) and having a triage process to ensure only patients considered as same day go to the SDEC.
• Ensuring all medical discharges are completed by 19:00.
• Identifying a space on the Royal Cornwall Hospital site for acute GPs to return to site.
• Making two bays on Acute Medical Unit (AMU) admissions bays.
• Supporting the move of acute medical resource from the emergency department to AMU with the intention of improving short stay performance on AMU.
• Intention to stop the use of Boarding, where patients are sent from an admitting area to a receiving ward prior to a bed being available.
Urgent care improvements include expanding services at West Cornwall Hospital and engaging stakeholders to improve community care alternatives. The trust is also learning from best practice in other hospitals across the country, and the Emergency Care Intensive Support Team are supporting the trust with bringing peer support with clinicians from other trusts to help increase the speed of delivery of their models.
The overall urgent care position in the region is supported by ongoing system actions, including a system clinical leaders event in August which focussed on clinically led plans to maximise community alternatives and update models to improve the urgent care access standards for Cornwall. The Chief Operating Officer at RCHT reports weekly on improvement actions being taken.
At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.
In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.
Regarding the concern raised about discharge delays, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
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56-Day Deadline
23 Sep 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29/7/24, I concluded the inquest into the death of Colonel John Frederick Codd (Bill) who died on 16/1/24 at the age of 88.
I recorded the cause of death as: 1a) Massive rectus sheath haematoma and severe coronary artery atherosclerosis; II) Essential hypertension.
I recorded a Narrative conclusion that Colonel Codd died from an Accident. There was a delay in the arrival of an ambulance and a further delay in admitting Colonel Codd from the ambulance into the Emergency Department. It is probable that an earlier admission into ED would have resulted in an earlier CT scan that would have revealed the haematoma that developed. It is possible that a blood transfusion could have been arranged that may have avoided the outcome.
I recorded the cause of death as: 1a) Massive rectus sheath haematoma and severe coronary artery atherosclerosis; II) Essential hypertension.
I recorded a Narrative conclusion that Colonel Codd died from an Accident. There was a delay in the arrival of an ambulance and a further delay in admitting Colonel Codd from the ambulance into the Emergency Department. It is probable that an earlier admission into ED would have resulted in an earlier CT scan that would have revealed the haematoma that developed. It is possible that a blood transfusion could have been arranged that may have avoided the outcome.
Circumstances of the Death
On 16/1/24, Colonel Codd fell over while exiting a taxi that had collected him after an appointment with his GP. An ambulance was called at 12:31 and the initial disposition was for a Category 3 response requiring 90% of attendances within 2 hours and an average of 60 minutes. The ambulance arrived at 14:49, left the scene at 15:46 and arrived at Royal Cornwall Hospital at 16:30. Although there was a delay in ambulance attendance, I felt this was relatively modest and unlikely to have been a contributory factor in the death. Information Classification: CONTROLLED National guidance requires a handover to hospital staff within 15 minutes. Unfortunately, the hospital was full and Colonel Codd remained in an ambulance outside the hospital until he was brought into a bed in the Majors 2 part of the ED at 21:11, approximately 4 hours and 40 minutes after arrival. At 22:10, Colonel Codd was found collapsed in cardiac arrest. He could not be resuscitated. At inquest, I heard from , one of the ED consultants at the hospital. I accepted his evidence that had there been a timely admission;
- An x-ray to confirm/exclude a hip fracture would have been conducted earlier;
- A CT scan ordered to elucidate the findings of the x-ray would then have been ordered earlier (the CT was not conducted);
- It was probable the CT scan would have revealed the haematoma from which Colonel Codd died;
- It was possible that a blood transfusion could have been organised that would have avoided the death.
- An x-ray to confirm/exclude a hip fracture would have been conducted earlier;
- A CT scan ordered to elucidate the findings of the x-ray would then have been ordered earlier (the CT was not conducted);
- It was probable the CT scan would have revealed the haematoma from which Colonel Codd died;
- It was possible that a blood transfusion could have been organised that would have avoided the death.
Action Should Be Taken
It is not for a coroner to make recommendations and so I leave you to consider how best to help ease the pressures that continue to be felt in the ED at Royal Cornwall Hospital. Information Classification: CONTROLLED
Copies Sent To
Royal Cornwall Hospital
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.