Harold Pedley
PFD Report
All Responded
Ref: 2023-0316
All 2 responses received
· Deadline: 27 Oct 2023
Coroner's Concerns (AI summary)
Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.
View full coroner's concerns
Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk. Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it. Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.
Responses
Action Taken
Lancashire and South Cumbria Integrated Care Board outlines actions taken by Blackpool Victoria Hospital, including revised communication protocols, staff training on triage and escalation, and direct GP referrals. They also detail how the ICB Primary Care Team is involved in communications with General Practices. (AI summary)
Lancashire and South Cumbria Integrated Care Board outlines actions taken by Blackpool Victoria Hospital, including revised communication protocols, staff training on triage and escalation, and direct GP referrals. They also detail how the ICB Primary Care Team is involved in communications with General Practices. (AI summary)
View full response
Dear Mr Wilson
Regulation 28 report - Harold Derek Pedley inquest 17 August 2023
Thank you for your letter dated 1 September 2023 sent following the conclusion of the inquest touching the death of Harold Derek Pedley (known as Derek).
I know that you will share my response with Mr Pedley’s family and I first want to express my sincere condolences to them.
Through the Regulation 28 report you have raised three matters of concern relating to the care Mr Pedley received when he attended Blackpool Victoria Hospital; this letter is in response to these issues and I will respond to each matter raised separately.
Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
AND
Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not
Page 2 being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
As you have recognised and in response to the current pressures facing acute trusts (in this case the Emergency Department), NHS England published a revised Operation Pressures Escalation Levels (OPEL) Framework 2023/24 in August 2023. Lancashire and South Cumbria Integrated Care Board (LSC ICB), through its System Co-ordination Centre (SCC), is currently leading a piece of work to implement this new framework consistently across the LSC system by November 2023. In addition to a new methodology for calculating OPEL levels which will allow for greater differentiation of hospitals under pressure, the new framework mandates a series of “action cards” to be implemented at each of the OPEL levels both by the hospital Trust, and by the wider health and care system. These incorporate a range of prescribed actions aimed at reducing the pressure on the hospital, safely improving flow within the hospital and prioritising patient and staff safety; it will be supplemented by locally agreed actions as we work through the implementation. In addition, the updated SCC guidance for Winter 2023 clarifies the role of the SCC in co-ordinating a response across the full LSC system in order to reduce risk in individual Trusts where there is potential to provide support from other providers within the system i.e. mutual aid.
Linked to the OPEL framework described above, where Blackpool Victoria Hospital is under significant pressure, Blackpool Teaching Hospitals will deploy its Full Capacity Protocol to de- escalate and address overcrowding with the Emergency Department, to spread risk, improve flow and keep patients safe. In such circumstances, and where necessary, a multi-agency approach is deployed in the form of tactical command response where health and care partners come together to agree and implement a range of immediate actions to de-escalate the hospital pressures which, for example, may include: freeing community capacity to enable more timely discharges; running multi-agency discharge events; community healthcare staff in-reaching to the Emergency Department to assess for alternative care pathways to prevent admission; and rapid specialty in-reach to urgent and emergency care pathways, so that patients requiring admission are moved from the Emergency Department.
There are significant pressures across urgent and emergency care pathways at Blackpool Victoria Hospital along with the other hospitals in Lancashire and South Cumbria. The ICB and the trusts are committed to taking action to relieve these pressures, primarily by promoting hospital avoidance, maximising hospital flow and improving discharge, so that patients have access to the right care, in the right place and in a timely way. There are a range of developments in progress at Blackpool Vitoria Hospital and in the community across the Fylde Coast. For example, the final phase of the major refurbishment of the Emergency Village at Blackpool Victoria Hospital is due to be completed in December 2023, which will provide more capacity and improved flow in the Emergency Department. Additionally, there are plans in place to expand virtual wards and maximise their use for both hospital avoidance and discharge over the winter period and by April 2024.
Across the Lancashire and South Cumbria health and care system, NHS England’s 10 high impact interventions to support urgent and emergency care recovery are being prioritised according to local needs and circumstances. For the Fylde Coast, inpatient flow, intermediate care, care transfer hubs and single point of access are the four high impact interventions that have been prioritised locally to also support improvements in hospital avoidance, flow and discharge, alongside the Patient Flow Improvement Programme led by the Trust.
Page 3 From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department. A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.
Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.
As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival. If there is no bed/space for the patient with the speciality team then the patient will remain in ED until a bed becomes available and the speciality team are required to attend ED and visit the patient and complete any required assessments. The learning will also be cascaded across other Trusts. With regards to direct referrals from GPs to the surgical team in Blackpool Victoria going forwards the surgical team have provided re-assurance in all instances that the GP will be advised of the estimated wait times within ED so that this can also be relayed to the patient prior to their arrival at ED.
In respect of the Primary Care element of your concern the ICB Primary Care Team forms part of the SCC arrangements.
As part of these arrangements, Trusts routinely request:
• Situational awareness communications to be sent to General Practices and Primary Care Networks (identified services are under pressure and any referred patients can expect delays)
• Service reminder communications to be sent to General Practices and Primary Care Networks (please use identified services to reduce pressure on other services)
Page 4 These communications are sent via an established newsflash system.
In addition, Trusts routinely request primary care clinical and managerial colleagues to join local ‘pressure response’ arrangements which may also result in the above communications and other actions to mitigate pressures. Again the learning from this tragic case will be shared across Lancashire and South Cumbria Primary Care network for awareness and vigilance in times of sustained pressure.
I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me.
Regulation 28 report - Harold Derek Pedley inquest 17 August 2023
Thank you for your letter dated 1 September 2023 sent following the conclusion of the inquest touching the death of Harold Derek Pedley (known as Derek).
I know that you will share my response with Mr Pedley’s family and I first want to express my sincere condolences to them.
Through the Regulation 28 report you have raised three matters of concern relating to the care Mr Pedley received when he attended Blackpool Victoria Hospital; this letter is in response to these issues and I will respond to each matter raised separately.
Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
AND
Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not
Page 2 being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
As you have recognised and in response to the current pressures facing acute trusts (in this case the Emergency Department), NHS England published a revised Operation Pressures Escalation Levels (OPEL) Framework 2023/24 in August 2023. Lancashire and South Cumbria Integrated Care Board (LSC ICB), through its System Co-ordination Centre (SCC), is currently leading a piece of work to implement this new framework consistently across the LSC system by November 2023. In addition to a new methodology for calculating OPEL levels which will allow for greater differentiation of hospitals under pressure, the new framework mandates a series of “action cards” to be implemented at each of the OPEL levels both by the hospital Trust, and by the wider health and care system. These incorporate a range of prescribed actions aimed at reducing the pressure on the hospital, safely improving flow within the hospital and prioritising patient and staff safety; it will be supplemented by locally agreed actions as we work through the implementation. In addition, the updated SCC guidance for Winter 2023 clarifies the role of the SCC in co-ordinating a response across the full LSC system in order to reduce risk in individual Trusts where there is potential to provide support from other providers within the system i.e. mutual aid.
Linked to the OPEL framework described above, where Blackpool Victoria Hospital is under significant pressure, Blackpool Teaching Hospitals will deploy its Full Capacity Protocol to de- escalate and address overcrowding with the Emergency Department, to spread risk, improve flow and keep patients safe. In such circumstances, and where necessary, a multi-agency approach is deployed in the form of tactical command response where health and care partners come together to agree and implement a range of immediate actions to de-escalate the hospital pressures which, for example, may include: freeing community capacity to enable more timely discharges; running multi-agency discharge events; community healthcare staff in-reaching to the Emergency Department to assess for alternative care pathways to prevent admission; and rapid specialty in-reach to urgent and emergency care pathways, so that patients requiring admission are moved from the Emergency Department.
There are significant pressures across urgent and emergency care pathways at Blackpool Victoria Hospital along with the other hospitals in Lancashire and South Cumbria. The ICB and the trusts are committed to taking action to relieve these pressures, primarily by promoting hospital avoidance, maximising hospital flow and improving discharge, so that patients have access to the right care, in the right place and in a timely way. There are a range of developments in progress at Blackpool Vitoria Hospital and in the community across the Fylde Coast. For example, the final phase of the major refurbishment of the Emergency Village at Blackpool Victoria Hospital is due to be completed in December 2023, which will provide more capacity and improved flow in the Emergency Department. Additionally, there are plans in place to expand virtual wards and maximise their use for both hospital avoidance and discharge over the winter period and by April 2024.
Across the Lancashire and South Cumbria health and care system, NHS England’s 10 high impact interventions to support urgent and emergency care recovery are being prioritised according to local needs and circumstances. For the Fylde Coast, inpatient flow, intermediate care, care transfer hubs and single point of access are the four high impact interventions that have been prioritised locally to also support improvements in hospital avoidance, flow and discharge, alongside the Patient Flow Improvement Programme led by the Trust.
Page 3 From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department. A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.
Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.
As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival. If there is no bed/space for the patient with the speciality team then the patient will remain in ED until a bed becomes available and the speciality team are required to attend ED and visit the patient and complete any required assessments. The learning will also be cascaded across other Trusts. With regards to direct referrals from GPs to the surgical team in Blackpool Victoria going forwards the surgical team have provided re-assurance in all instances that the GP will be advised of the estimated wait times within ED so that this can also be relayed to the patient prior to their arrival at ED.
In respect of the Primary Care element of your concern the ICB Primary Care Team forms part of the SCC arrangements.
As part of these arrangements, Trusts routinely request:
• Situational awareness communications to be sent to General Practices and Primary Care Networks (identified services are under pressure and any referred patients can expect delays)
• Service reminder communications to be sent to General Practices and Primary Care Networks (please use identified services to reduce pressure on other services)
Page 4 These communications are sent via an established newsflash system.
In addition, Trusts routinely request primary care clinical and managerial colleagues to join local ‘pressure response’ arrangements which may also result in the above communications and other actions to mitigate pressures. Again the learning from this tragic case will be shared across Lancashire and South Cumbria Primary Care network for awareness and vigilance in times of sustained pressure.
I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me.
Action Taken
DHSC acknowledges concerns about A&E wait times and refers to NHS England's 'Delivery plan for recovering urgent and emergency care services' which includes a target to improve A&E wait times. They cite dedicated funding to increase staffed hospital beds and improvements in performance at Blackpool Teaching Hospitals NHS Foundation Trust. (AI summary)
DHSC acknowledges concerns about A&E wait times and refers to NHS England's 'Delivery plan for recovering urgent and emergency care services' which includes a target to improve A&E wait times. They cite dedicated funding to increase staffed hospital beds and improvements in performance at Blackpool Teaching Hospitals NHS Foundation Trust. (AI summary)
View full response
Dear Mr Wilson,
Thank you for your letter of 1 September 2023 to the Secretary of State for Health and Social Care regarding the death of Harold Derek Pedley. I am replying as 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 saddened I was to read of the circumstances of Mr Pedley’s death and I offer my sincere condolences to his family and loved ones. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so 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) and the Care Quality Commission (CQC).
I understand that Lancashire and South Cumbria Integrated Care Board have responded to you directly on the specific actions being taken locally to address the concerns you have raised. Further, the CQC has advised my officials that they continue to have regular engagement with Blackpool Teaching Hospitals NHS Foundation Trust to monitor waiting time performance and risk.
Your report highlights a delay following a GP referral from primary to secondary care. NHS England has confirmed that all referrals to Emergency Departments and secondary care should have an accompanying letter to inform staff of the concerns and patient history. Hospitals should also have access to the Summary Care Record; a national database that holds electronic records of important patient information, intended to provide a summary of patients’ GP records. Further developments are ongoing to make referrals to secondary care more efficient.
Your report also raises concerns about long A&E wait times and the pressures on staff, specifically due to bed availability. As the Minister responsible for urgent and emergency care services, I recognise the significant pressures the NHS is facing and the impact on waiting time for patients. In January 2023, NHS England published a two year ‘Delivery plan for recovering urgent and emergency care services’ with a target for this year to improve A&E wait times to a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025. 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
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. In addition, to improve capacity of the local system, Lancashire Teaching Hospitals NHS Foundation Trust (LTHNFT) and East Lancashire Hospitals NHS Trust (ELHNT) received £15 million and £4.9 million respectively from a £250 million programme to increase NHS capacity in 2023/24.
Since publication of the plan in January 2023, there have been improvements in performance. In April 2024, 79.8% of patients at Blackpool Teaching Hospitals NHS Foundation Trust A&E were admitted, referred, or discharged in 4 hours, an increase of 0.9ppt from March 2024.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Thank you for your letter of 1 September 2023 to the Secretary of State for Health and Social Care regarding the death of Harold Derek Pedley. I am replying as 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 saddened I was to read of the circumstances of Mr Pedley’s death and I offer my sincere condolences to his family and loved ones. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so 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) and the Care Quality Commission (CQC).
I understand that Lancashire and South Cumbria Integrated Care Board have responded to you directly on the specific actions being taken locally to address the concerns you have raised. Further, the CQC has advised my officials that they continue to have regular engagement with Blackpool Teaching Hospitals NHS Foundation Trust to monitor waiting time performance and risk.
Your report highlights a delay following a GP referral from primary to secondary care. NHS England has confirmed that all referrals to Emergency Departments and secondary care should have an accompanying letter to inform staff of the concerns and patient history. Hospitals should also have access to the Summary Care Record; a national database that holds electronic records of important patient information, intended to provide a summary of patients’ GP records. Further developments are ongoing to make referrals to secondary care more efficient.
Your report also raises concerns about long A&E wait times and the pressures on staff, specifically due to bed availability. As the Minister responsible for urgent and emergency care services, I recognise the significant pressures the NHS is facing and the impact on waiting time for patients. In January 2023, NHS England published a two year ‘Delivery plan for recovering urgent and emergency care services’ with a target for this year to improve A&E wait times to a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025. 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
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. In addition, to improve capacity of the local system, Lancashire Teaching Hospitals NHS Foundation Trust (LTHNFT) and East Lancashire Hospitals NHS Trust (ELHNT) received £15 million and £4.9 million respectively from a £250 million programme to increase NHS capacity in 2023/24.
Since publication of the plan in January 2023, there have been improvements in performance. In April 2024, 79.8% of patients at Blackpool Teaching Hospitals NHS Foundation Trust A&E were admitted, referred, or discharged in 4 hours, an increase of 0.9ppt from March 2024.
Thank you once again for bringing these concerns to my attention.
Yours,
HELEN WHATELY
Sent To
- Department of Health and Social Care
- Lancashire and South Cumbria Integrated Care Board
Response Status
Linked responses
2 of 2
56-Day Deadline
27 Oct 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
Report Sections
Investigation and Inquest
The death of Harold Derek PEDLEY Otherwise known as Derek PEDLEY on 21.12.22 at Blackpool Victoria Hospital was reported to me and I opened an investigation, which concluded by way of an inquest held on 17th August 2023. I determined that the medical cause of Mr. Pedley’s death was: 1 a Small bowel ischaemia 1 b Severe Superior mesenteric artery atheroma II Left ventricular hypertrophy; severe coronary artery atheroma
In box 3 of the Record of Inquest I recorded as follows: Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his Friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non - survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease. The conclusion of the Coroner was Natural causes
In box 3 of the Record of Inquest I recorded as follows: Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his Friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non - survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease. The conclusion of the Coroner was Natural causes
Circumstances of the Death
In addition to the contents of section 3 above, the following is of note: This inquest was about a man who, aged 90, died whilst waiting to be seen by a medical professional in hospital. He did not simply arrive at hospital, but had been assessed and then sent there by his GP, who felt, rightly as it turned out, that Derek may have developed an obstruction. He was anticipating Derek would be seen quickly. He arrived at the Emergency Department, and handed in some paperwork at reception and understandably expected he would not have to wait long to be assessed by doctors who he knew were expecting him. No-one called for him for almost two hours by which time he had died. It is correct to say that once a post mortem examination was performed, it was clear that even if he had been assessed immediately upon arrival at hospital his condition was such that surgical intervention was not a realistic possibility and the condition was going to prove terminal. At the time Derek arrived, as the Hospital Trust’s own internal review of this death explained, such were the pressures on the hospital Trust posed by patient numbers that it was operating at OPEL [Operations Pressure Escalation Level] 4. This is a method used by the NHS to measure the stress, demands, and pressure a hospital is under. OPEL 4 represents the highest level, when a hospital is “unable to deliver comprehensive care, and patient safety is at risk”.
At the time of Derek’s death, there was a “Streaming” Nurse working on the Emergency Department whose role it was to undertake initial basic observations and assess the risk of the patients waiting and to prioritise them. However, due to the pressures on the department she was unable to perform that role. Had she had the time to carry out her role as expected, it is likely Derek would have been seen much earlier. The Emergency Department staff were also under such pressure they did not have the time to notify the doctors who were expecting Derek’s arrival at hospital that he had arrived. Those doctors were under similar pressures and had not had the opportunity to check whether Derek had arrived. Staffing levels had been reduced suddenly for that shift due to staff illness and no additional staff could be made available as a replacement. Even though a GP had referred Derek on the basis he would not have to spend time in the Emergency Department before being seen on the surgical assessment unit, in reality this was not going to be the case because as the author of the Trust’s internal review told the court, due to a lack of beds on the Surgical Assessment Unit, a patient arriving at the Emergency Department such as Derek will almost always have to remain in the Emergency Department for some time waiting for a bed to become available. The author of the Trust’s review, an impressive and candid witness, acknowledged that although on the day on which Derek died was particularly busy, the Emergency Department is regularly subject to these levels of pressure and they are by no means limited to the winter months. The author also explained how the situation may be eased to some degree were perhaps two surgical beds to remain free for when patients such as Derek arrive in the Emergency Department, but this has not been possible to date. Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been an understandable reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive.
At the time of Derek’s death, there was a “Streaming” Nurse working on the Emergency Department whose role it was to undertake initial basic observations and assess the risk of the patients waiting and to prioritise them. However, due to the pressures on the department she was unable to perform that role. Had she had the time to carry out her role as expected, it is likely Derek would have been seen much earlier. The Emergency Department staff were also under such pressure they did not have the time to notify the doctors who were expecting Derek’s arrival at hospital that he had arrived. Those doctors were under similar pressures and had not had the opportunity to check whether Derek had arrived. Staffing levels had been reduced suddenly for that shift due to staff illness and no additional staff could be made available as a replacement. Even though a GP had referred Derek on the basis he would not have to spend time in the Emergency Department before being seen on the surgical assessment unit, in reality this was not going to be the case because as the author of the Trust’s internal review told the court, due to a lack of beds on the Surgical Assessment Unit, a patient arriving at the Emergency Department such as Derek will almost always have to remain in the Emergency Department for some time waiting for a bed to become available. The author of the Trust’s review, an impressive and candid witness, acknowledged that although on the day on which Derek died was particularly busy, the Emergency Department is regularly subject to these levels of pressure and they are by no means limited to the winter months. The author also explained how the situation may be eased to some degree were perhaps two surgical beds to remain free for when patients such as Derek arrive in the Emergency Department, but this has not been possible to date. Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been an understandable reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive.
Copies Sent To
, Medical Director, Blackpool Teaching Hospitals NHS Foundation Trust
Inquest Conclusion
Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his Friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non - survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease. The conclusion of the Coroner was Natural causes
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.