UK Inquiry Tracker

Joseph Maunick

PFD Report All Responded Ref: 2023-0128

Date of Report 20 April 2023

Coroner Peter Taheri

Coroner Area Suffolk

Response Deadline ✓ from report 15 June 2023

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 2 responses received · Deadline: 15 Jun 2023

Coroner's Concerns (AI summary)

National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing their risk of harm.

View full coroner's concerns

1) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements, such that those in similar need do not receive suitable care, then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case.
2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future.

Responses

NHS England NHS / Health Body

20 Apr 2023

Action Planned
NHS England is working with Integrated Care Systems to streamline pathways for older adults, including people with dementia, and is focused on improving retention and staff attendance through the NHS People Promise; they will also expand community services including more joined-up care for older people living with frailty and improve falls services. (AI summary)

View full response

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Mr Joseph Willy Maunick (Will) who died on 15 March 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 April 2023 concerning the death of Mr Joseph Willy Maunick (“Will”) on 15 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Will’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Will’s care have been listened to and reflected upon.

The first concern you raised related to a national social care shortage, and the impact this has had on the quality of care provided to Will. The Department of Health and Social Care (DHSC) are best placed to comment on this issue as they hold responsibility for social care provision. The DHSC have committed to adult social care reform and have committed £700 million to transform and improve the adult social care system in England, to include around access to support and joining up of services as part of their ‘People at the Heart of Care’ plan.

Your second concern highlighted the severe pressures being placed on West Suffolk Hospital, including its Emergency Department (ED), and the significant impact on resourcing this was having. Your Report concludes that Will was not able to receive the supervision he required or be transferred to a more appropriate ward at an earlier opportunity.

We have engaged with West Suffolk NHS Foundation Trust regarding Will’s care on his admission to the ED as a social admission on 4 March 2022, while diagnosed with dementia and at risk of falls. At the time of Will’s admission, the Trust was operating under an internal critical incident, due to a lack of flow and shortage of available beds. As a result of these pressures Will was in the ED for a total of 15.5 hours. It is documented that he fell in the ED despite receiving 1:1 supervision at the time of his fall which resulted in a left subdural haematoma which he did not recover from. He received palliative care until he passed away on 15 March 2022.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

12 June 2023

Actions have now been taken locally to minimise the risk of such an incident from happening again at the Trust. These actions include:

- The Trust plan to share a report with the Integrated Care Board (ICB) Quality and Safety Teams to raise awareness of available community resources. This will align with reducing the lack of available resource/facilities in the community to provide emergency placement/respite resulting in an avoidable hospital admission.
- A review will be undertaken with ED staff to support the development of appropriate pathways for vulnerable patients suffering with conditions such as dementia and those at high risk of falls to ensure support is available in making clinical decisions and ability to escalate a patient as a priority for a ward bed.
- A pilot of a quality improvement project within the ED will be undertaken to raise awareness of high risk falls patients and a thematic review of falls within the ED will also be undertaken. This will identify any wider themes and areas for further learning and improvement. The Trust will also ensure that assistive technology is available to staff to support in identifying when a patient is mobilising.

In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia. Falls are the number one single reason why older people are taken to the emergency department, and around 30% of people aged 65 and over will fall at least once a year.

It is one of the core objectives of NHS England’s 2023/24 Operational Planning Guidance to improve retention and staff attendance, through a systematic focus on all elements of the NHS People Promise. This includes taking advantage of opportunities to deploy staff more flexibly, improving staff experience and increasing productivity. Nationally, there are also clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day.

I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Department of Health and Social Care Central Government

17 Jun 2024

Noted
The DHSC acknowledges concerns about resourcing pressures in emergency departments and insufficient provision of care, noting that these are being monitored and that local authorities have a duty to shape their care market. (AI summary)

View full response

Dear Peter,

Thank you for your letter of 20th April 2023 about the death of Mr Joseph Willy Maunick. I am replying as Minister with responsibility for adult social care.

Firstly, I would like to say how saddened I was to read of the circumstances of Joseph’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

I am aware that the National Medical Director of NHS England, has responded in detail to the serious concerns you have raised regarding the national severe resourcing pressures in emergency departments (ED).

The report highlights pressures within EDs that continue to be monitored by the Trust. The Care Quality Commission (CQC) were also made aware of the report following the incident. Resourcing of ED services and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust. More broadly, CQC continues to monitor waiting times and other national targets. They also carry out inspections of urgent and emergency services in trusts that are performing poorly in line with national ED targets as part of the current risk-based inspection model.

With regard to your concern about a potential national care shortage and insufficient provision of care, including residential care placements, under the Care Act, local authorities are tasked with the duty to shape their care market to ensure a diverse range of high quality, sustainable, person-centred care and support services are provided.

A duty on the Care Quality Commission (CQC) to assess LAs’ delivery of their adult social care duties went live on 1 April 2023 and the roll out of formal assessments to all 153 local

authorities commenced in December 2023. If CQC identify a serious failure, new powers would allow the Secretary of State to intervene to drive improvement.

Last year, £16m was provided to partners to make support available including a focus on how local authorities commission the right kind of care to meet the needs of everyone who draws on care and support. Secretary of State powers also require adult social care providers to share their data with us to allow for more awareness and insight on what is happening locally and nationally.

Thank you for bringing these concerns to my attention.

Helen Whately

Sent To

Department of Health and Social Care
NHS England

Response Status

Linked responses 2 of 2

56-Day Deadline 15 Jun 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

On 18th March 2022 an investigation was commenced into the death of Joseph Willy Maunick. The investigation concluded at the end of the inquest on 18th April 2023. The narrative conclusion of the inquest was that: Joseph Willy Maunick (Will) died on 15th March 2022 as a result of a severe head injury that he suffered in a fall in the Emergency Department of West Suffolk Hospital on 4th March 2022. He was in the Emergency Department as a social admission, while his wife was going through unplanned emergency major surgery. Will was not safe to be left alone at home and required care around the clock. Exhaustive efforts to find appropriate care while his wife was in hospital were unsuccessful, so he had been admitted to a hospital Emergency Department as a last resort. This was not the most suitable environment for a gentleman with dementia who was a falls risk and required constant supervision. The situation was exacerbated by pre-existing severe pressures on the Emergency Department on that day due to high demand for beds, without the availability of beds to meet the demand, and a severe deficiency of staff. The scarcity of resource, relative to demand, at the hospital also contributed to Will not being transferred to a ward sooner. While there was no specific failure by an individual that contributed to the death, Will’s death was contributed to by the lack of availability of more appropriate care. The medical cause of death was confirmed as: 1(a) Subdural Haematoma 1(b) Fall 2 Dementia, Complete Heart Block, Frailty

Circumstances of the Death

Joseph Willy Maunick (Will) was an intelligent man, gifted with communication skills, who worked as a teacher and spoke multiple languages. In his later years he developed cognitive impairment, which in turn led to him being at very high risk of falls. This risk, in relation to which he needed constant supervision, was known to those caring for him and to those responsible for looking after him when he was admitted to the Emergency Department of the West Suffolk Hospital on 4th March 2022. He was admitted to the hospital Emergency Department not because he himself was experiencing a medical emergency, but as a last resort after exhaustive efforts to explore all options before Will was admitted to hospital: it proved not to be possible to find suitable alternative care for him in residential care placements while his wife, and main carer, underwent unplanned emergency major surgery. The inquest heard evidence that, prior to his admission to hospital, at least eight social care providers were contacted plus further residential homes, but none of them could provide emergency care for Will. The inquest heard undisputed evidence that this was an instance of a national care shortage. The inquest heard evidence that in an Emergency Department where many patients are suffering medical emergencies constant one-to-one supervision will not always be possible. I found as a fact that it was not possible on this occasion and that Will’s fall in the Emergency Department took place when the nursing assistant who was trying to maintain constant one-to-one supervision of Will insofar as possible had their attention momentarily diverted to another patient experiencing a medical emergency. I judged that it would not be just to describe this as a failure on the part of the nursing assistant or the Emergency Department staff. The reason why it was not an individual failure included that the inquest heard evidence that the hospital, and in particular the Emergency Department, was experiencing significant pressures associated with high demand and an internal critical incident had been declared. There was a high demand for beds within the hospital without the availability of beds to meet the demand. This included the facts that there were, at the time of Will’s arrival in the Emergency Department, 50 patients in the Emergency Department, of whom 32 were waiting for bed placement. Moreover, staffing was at a ‘black status’ (the worst level) across the hospital, with a deficiency of staff of around 60 nurses and nursing assistants. I found as a fact that those severe pressures – the high demand levels and the deficiency of staff and scarcity of resource – contributed to the death. Firstly, if it had been possible to care for and supervise Will on a constant basis as he needed, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. Secondly, on the balance of probabilities, the scarcity of resource relative to demand contributed to Will not being transferred to a ward – or other more appropriate environment – sooner. Apart from the inherent particular difficulties in providing constant supervision in an Emergency Department referred to above, the inquest also received undisputed evidence that the environment of a busy, noisy Emergency Department, with lights on at all hours of the day and night would be overly stimulating and not the most suitable environment for someone with cognitive impairment who was experiencing confusion and agitation. I found that such an environment probably contributed to Will’s inclination to wander and so to his fall. If it had been possible to transfer Will to a more suitable environment sooner, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. I found as a fact that, on the balance of probabilities, the lack of availability of more appropriate care contributed to the death.

Copies Sent To

West Suffolk NHS Foundation Trust Norfolk County Council Norfolk & Suffolk NHS Foundation Trust