Charles Rothwell
PFD Report
All Responded
Ref: 2022-0312
All 1 response received
· Deadline: 30 Nov 2022
Coroner's Concerns (AI summary)
Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.
View full coroner's concerns
1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care.
Responses
Noted
AACE acknowledges the coroner's concerns about ambulance response times and capacity and highlights that the issue has been flagged nationally, leading to a national demand and capacity modelling exercise led by NHSE. (AI summary)
AACE acknowledges the coroner's concerns about ambulance response times and capacity and highlights that the issue has been flagged nationally, leading to a national demand and capacity modelling exercise led by NHSE. (AI summary)
View full response
Dear Ms Welch
REGULATION 28: CHARLES STEPHEN ROTHWELL
I am writing in response to the Regulation 28 report to prevent future deaths concerning the death of Charles Stephen Rothwell which you issued on 5th Oct 2022 to the Association of Ambulance Chief Executives (AACE).
AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance service however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.
In your letter you have raised several areas of concern:
1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of
ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care.
Firstly, I would like to confirm that the issues you have raised here about capacity within NWAS are in fact a national issue for the ambulance sector and the response time delays that were experienced in this case are now present in every ambulance trust across the sector in England and also in the devolved nations to some extent.
As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.
Hospital handover delays are the single biggest factor and in some ambulance trusts up to one third of all their operational hours are being lost to handover delays. This results in patients coming to harm whilst waiting in ambulances to access the emergency department and also harm to patients waiting in the community as these ambulances are no longer able to respond to those patients.
The reason for these delays is complex but at the root of it is poor patient flow in the hospitals because they have large numbers of medically fit patients who are unable to be discharged due to a shortage of social care packages needed to ensure safe discharge. The resulting backlog means that ambulances cannot offload their patients within the stipulated 15 minutes and sadly in many areas we are seeing waits of several hours for patients to access ED.
This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem.
The second issue in play here is that we believe that ambulance services no longer have the required capacity nationally to routinely deliver the nationally mandated response time targets even if the current handover delay issues were eliminated. This is due to an inexorable rise in demand for our services and an increasing level of acuity in terms of the calls being received. AACE has flagged this issue nationally repeatedly over the last few years and has called for a national piece of demand and capacity modelling across the sector led by NHSE. I am pleased to say that this is now gaining traction and whilst in its early stages is being pursued by NHSE at the present time.
This national modelling around capacity will compliment that carried out locally by ambulance trusts and their local commissioners. Ambulance Trusts including NWAS regularly conduct sophisticated demand and capacity reviews to help inform negotiations with local commissioners and I am aware that in NWAS discussions are ongoing in this area.
I note in your letter that you have also addressed the PFD to the SoS for Health and Social Care and to the CEO of NHSE and this was absolutely appropriate as the system wide issues which lead to these delays must be tackled at a national level through a series of complex national initiatives designed to eliminate hospital handover delays and ensure that ambulance trusts have sufficient resources to manage demand going forward over the next five years and beyond.
AACE will continue to lobby for the changes required and will continue to support its member trusts to work with the wider health system to find solutions which protect patients and ensure that they get the service they need and should expect.
I hope this has answered your concerns.
If I may be of further assistance, please do not hesitate to make contact.
On behalf of AACE, I would also like to extend our sincere condolences to the family of Charles Rothwell.
REGULATION 28: CHARLES STEPHEN ROTHWELL
I am writing in response to the Regulation 28 report to prevent future deaths concerning the death of Charles Stephen Rothwell which you issued on 5th Oct 2022 to the Association of Ambulance Chief Executives (AACE).
AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance service however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.
In your letter you have raised several areas of concern:
1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of
ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of a shortage of hospital beds, which in turn is because of shortages in social care.
Firstly, I would like to confirm that the issues you have raised here about capacity within NWAS are in fact a national issue for the ambulance sector and the response time delays that were experienced in this case are now present in every ambulance trust across the sector in England and also in the devolved nations to some extent.
As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.
Hospital handover delays are the single biggest factor and in some ambulance trusts up to one third of all their operational hours are being lost to handover delays. This results in patients coming to harm whilst waiting in ambulances to access the emergency department and also harm to patients waiting in the community as these ambulances are no longer able to respond to those patients.
The reason for these delays is complex but at the root of it is poor patient flow in the hospitals because they have large numbers of medically fit patients who are unable to be discharged due to a shortage of social care packages needed to ensure safe discharge. The resulting backlog means that ambulances cannot offload their patients within the stipulated 15 minutes and sadly in many areas we are seeing waits of several hours for patients to access ED.
This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem.
The second issue in play here is that we believe that ambulance services no longer have the required capacity nationally to routinely deliver the nationally mandated response time targets even if the current handover delay issues were eliminated. This is due to an inexorable rise in demand for our services and an increasing level of acuity in terms of the calls being received. AACE has flagged this issue nationally repeatedly over the last few years and has called for a national piece of demand and capacity modelling across the sector led by NHSE. I am pleased to say that this is now gaining traction and whilst in its early stages is being pursued by NHSE at the present time.
This national modelling around capacity will compliment that carried out locally by ambulance trusts and their local commissioners. Ambulance Trusts including NWAS regularly conduct sophisticated demand and capacity reviews to help inform negotiations with local commissioners and I am aware that in NWAS discussions are ongoing in this area.
I note in your letter that you have also addressed the PFD to the SoS for Health and Social Care and to the CEO of NHSE and this was absolutely appropriate as the system wide issues which lead to these delays must be tackled at a national level through a series of complex national initiatives designed to eliminate hospital handover delays and ensure that ambulance trusts have sufficient resources to manage demand going forward over the next five years and beyond.
AACE will continue to lobby for the changes required and will continue to support its member trusts to work with the wider health system to find solutions which protect patients and ensure that they get the service they need and should expect.
I hope this has answered your concerns.
If I may be of further assistance, please do not hesitate to make contact.
On behalf of AACE, I would also like to extend our sincere condolences to the family of Charles Rothwell.
Sent To
Response Status
Linked responses
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56-Day Deadline
30 Nov 2022
All responses received
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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 7 January 2022 I commenced an investigation into the death of Charles Stephen Rothwell, who died on 6 January 2022 aged 69. The investigation concluded at the end of an inquest on 4 October 2022. The medical cause of death was 1a Lobar pneumonia and my conclusion was natural causes.
Circumstances of the Death
Charles Rothwell had a telephone consultation with his GP on 5 January 2022 and was diagnosed with a chest infection and prescribed oral antibiotics. During the afternoon of 6 January his condition significantly deteriorated.
In a 999 call made by staff to the North West Ambulance Service at 16.26h on 6 January he was correctly triaged as a Category 3, which should have resulted in attendance within 120 minutes but he was advised that there was likely to be a minimum 11 hour wait. In a second 999 call at 1726h he was again graded as Category 3 but reminded of the 11 hour wait. In a third 999 call at 1905h he was now coughing up blood and struggling to breath so was re-graded to Category 2. At the final 999 call at 1930h he was no longer breathing and was re-graded as Category 1. An ambulance arrived at 1937 but paramedics were unable to resuscitate Mr Rothwell.
The reason for the non-attendance was that demand for emergency paramedic response significantly outstripped supply.
Although I concluded that the delayed arrival of paramedics did not cause or contribute to the death, it is my opinion that ongoing lack of resources means there is a risk that future deaths will occur unless action is taken.
In a 999 call made by staff to the North West Ambulance Service at 16.26h on 6 January he was correctly triaged as a Category 3, which should have resulted in attendance within 120 minutes but he was advised that there was likely to be a minimum 11 hour wait. In a second 999 call at 1726h he was again graded as Category 3 but reminded of the 11 hour wait. In a third 999 call at 1905h he was now coughing up blood and struggling to breath so was re-graded to Category 2. At the final 999 call at 1930h he was no longer breathing and was re-graded as Category 1. An ambulance arrived at 1937 but paramedics were unable to resuscitate Mr Rothwell.
The reason for the non-attendance was that demand for emergency paramedic response significantly outstripped supply.
Although I concluded that the delayed arrival of paramedics did not cause or contribute to the death, it is my opinion that ongoing lack of resources means there is a risk that future deaths will occur unless action is taken.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.