Christina Ruse
PFD Report
All Responded
Ref: 2022-0265
All 2 responses received
· Deadline: 28 Nov 2022
Coroner's Concerns (AI summary)
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a patient's deterioration, raising concerns about future deaths despite recent service improvements.
View full coroner's concerns
1.EEAST were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes.
2. There were no emergency ambulances available to assign to this call due to high call demand.
3. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.
2. There were no emergency ambulances available to assign to this call due to high call demand.
3. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.
Responses
Action Taken
East of England Ambulance Service has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at hospitals in Norfolk to improve response times for critical patients, and shared a briefing for HM Coroners in relation to hospital handover delays. (AI summary)
East of England Ambulance Service has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at hospitals in Norfolk to improve response times for critical patients, and shared a briefing for HM Coroners in relation to hospital handover delays. (AI summary)
View full response
Dear Ms Lake Inquest into the death of Christina Avis Ruse am writing further to the inquest into the death of Christina which took place on 22 August 2022, and the concerns YoU raised in relation to the delay in EEAST attending: understand that Chris Hewetson gave evidence in relation to the steps the Trust was eakabliso to manage the current call demand and have requested a further review to esta if further steps should be taken in respect ofthis_ The Trust is working hard with our system partners across the region to ensure that our patients are safe this challenging period: Like all other ambulance trusts; we are also working with the Safety Investigation Branch (HSIB) to continue to escalate our concerns_ have attached our current delay action plan that has recently been reviewed. Ata local level, the Trust hasa number of ongoing actions in Norfolk aimed at addressing the handover delays Dac {(tegrated Care Boardbendcespeetise and other stakeholders, chaired by the ICE (Integrated Care Board) and respective hospitals and discuss any lengthy delays and interim measures that need to be put in place. The 'Category 1 drop and go' and s avaegore: rapid release' projects are also in place although these are always at the acute due to capacity To highlight the nature ofthe handover last month we lost hours of ambulance time outside hospitals in Norfolk waiting to handover; after the 15-minute handover (i.e. not including that time). This does account for the hours spent 'cohorting' patients, northe lost manager time supporting this As can be seen the effect on our Cz response time is hugely significant and correlates directly with delayed handovers. Escalations continue to take place regularly at executive levelto and ease this situation, but the trend nevertheless is still currently worsening_ Impact of Norfolk Hospital delays 7000 55-12 G000
40.48
26.24 5000 12 C0 4000
57.36 3000 43-12 2000 28-48 1000
14.24 OO.C0 "eyupsWU me Y wmrq 8 4-H>15 mins; hours lost Ruse, You duringealthcare" not delays, 6295 period not try
The initiative mentioned earlier relate to the 'Category 1 and go' process which means that if a Category 1 call is received and there is a crew waiting with a patient at hospital, the crew can drop their patient off immediately to attend to the Pategchas Equally, the 'Category 2 rapid release means that if a Category 2 patient Beernsseggedovterethe peooe byaridhiclace-ordimatorandrevatecoed abatielid Category call; the rapid release programme allows a crew to handover a patient at the hospital within 10 minutes to allow that crew to then attend to the Category 2 patient. The aim of these schemes isto help improve the response time to patients who are suffering with chest pain or potentially having a stroke_ Furthermore; the Association of Ambulance Chief Executives (AACE) released a briefing for HM Coroners in relation to hospital handover and delayed ambulance responses to 999 calls and this was shared with your office on 30 August 2022. have also attached a copy for your information. Tam sorry for the delay that Christina Ruse and her family experienced and would be grateful if you could pass a copY ofthis letter onto Christina s family.
40.48
26.24 5000 12 C0 4000
57.36 3000 43-12 2000 28-48 1000
14.24 OO.C0 "eyupsWU me Y wmrq 8 4-H>15 mins; hours lost Ruse, You duringealthcare" not delays, 6295 period not try
The initiative mentioned earlier relate to the 'Category 1 and go' process which means that if a Category 1 call is received and there is a crew waiting with a patient at hospital, the crew can drop their patient off immediately to attend to the Pategchas Equally, the 'Category 2 rapid release means that if a Category 2 patient Beernsseggedovterethe peooe byaridhiclace-ordimatorandrevatecoed abatielid Category call; the rapid release programme allows a crew to handover a patient at the hospital within 10 minutes to allow that crew to then attend to the Category 2 patient. The aim of these schemes isto help improve the response time to patients who are suffering with chest pain or potentially having a stroke_ Furthermore; the Association of Ambulance Chief Executives (AACE) released a briefing for HM Coroners in relation to hospital handover and delayed ambulance responses to 999 calls and this was shared with your office on 30 August 2022. have also attached a copy for your information. Tam sorry for the delay that Christina Ruse and her family experienced and would be grateful if you could pass a copY ofthis letter onto Christina s family.
Action Taken
Spire Norwich Hospital has added wording to patient admission letters to ensure all patients are aware that the hospital does not have an on-site critical care unit, and has agreed a process with East of England Ambulance Service for clinician to clinician discussions regarding inter-provider transfers. (AI summary)
Spire Norwich Hospital has added wording to patient admission letters to ensure all patients are aware that the hospital does not have an on-site critical care unit, and has agreed a process with East of England Ambulance Service for clinician to clinician discussions regarding inter-provider transfers. (AI summary)
View full response
Dear Madam Following the three inquests held earlier this year in relation to the deaths of Christina Ruse, I am writing to update you on actions taken in response to t he recommendations you made:
• Ensure all patients admitted to Spire Norwich Hospital are aware that the hospital does not have an on-site critical care unit
• In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required In order to ensure all patients are aware that Spire Norwich Hospital does not have a critical care unit, we have added the following wording to patient admission letters: In the unlikely event of an unforeseen emergency requiring special ist care or facilities not available at Spire Norwich Hospital, it may be necessary to transfer you to the Norfolk and Norwich University Hospital. If this is necessary, it will be as an NHS patient, as many services are simply not provided privately in these circumstances, and rapid emergency NHS treatment would be in your best interest. I met with Patient Safety Officer (EEAST) and , Control Room Lead (EEAST) on the 13th October 2022 to discuss options to improve ambulance response times for inter- provider transfers. We discussed the pressure facing the ambulance service at this time in great detail and took the time to explain that it would not be possible to provide any assurance regarding ambulance response times or to agree an early notification or booking service as you had suggested, due to the requirement to man;ip.e demand through thP. existing triage and prioritisation system. However, we did acknowledge th at the ability to have a clinician to clinician discussion, where Spire senior nursing or medical staff can speak to a clinical lead within EEAST would enable detailed information to be provided regarding the ra tionale for transfer and patient condition. This would provide the ambulance service with rnore clinical inform.ition to assist with prioritisation of resources along with providing Spire staff more information in relation to waiting times, thus assisting with patient care management plans whilst awaiting transfer. Therefore, we have agreed the fol lowing;
• On occasions where a delayed response to an IFT request is advised the caller may wish to speak to the EOC Clinical Co-ordinator directly, or request a clinical review, for consideration of a Priority Response, Rapid Release or Drop and Go to facilitate a more prompt response.
Details of the request, including caller contact narne and number, and a brief surnrnary of any information pertinent to the request (such as treatment window or risk of deterioration) should he r@r.orded in CAD not@s ;ino escalated to the Clinical Co-ordinator throu8h norm;il escalation channPls.
• The EOC Clinicdl Co-ordinator is to review any such request as per norrnal process and decision making taking into account community risk and demand. Any decision must be communicated to the clinician making the IFT request and relevant dispc.1tch team as required. We continue to consider other options to support timely transfer of patients, including liaison with private ambulance providers. The challenges w ith ambulance transfer delays have been rPportPd to Spire Healthcare's Executive committee and we are being supported to seek solutions to this challenge at a national level. Kind regards
Director of Clinical Services
• Ensure all patients admitted to Spire Norwich Hospital are aware that the hospital does not have an on-site critical care unit
• In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required In order to ensure all patients are aware that Spire Norwich Hospital does not have a critical care unit, we have added the following wording to patient admission letters: In the unlikely event of an unforeseen emergency requiring special ist care or facilities not available at Spire Norwich Hospital, it may be necessary to transfer you to the Norfolk and Norwich University Hospital. If this is necessary, it will be as an NHS patient, as many services are simply not provided privately in these circumstances, and rapid emergency NHS treatment would be in your best interest. I met with Patient Safety Officer (EEAST) and , Control Room Lead (EEAST) on the 13th October 2022 to discuss options to improve ambulance response times for inter- provider transfers. We discussed the pressure facing the ambulance service at this time in great detail and took the time to explain that it would not be possible to provide any assurance regarding ambulance response times or to agree an early notification or booking service as you had suggested, due to the requirement to man;ip.e demand through thP. existing triage and prioritisation system. However, we did acknowledge th at the ability to have a clinician to clinician discussion, where Spire senior nursing or medical staff can speak to a clinical lead within EEAST would enable detailed information to be provided regarding the ra tionale for transfer and patient condition. This would provide the ambulance service with rnore clinical inform.ition to assist with prioritisation of resources along with providing Spire staff more information in relation to waiting times, thus assisting with patient care management plans whilst awaiting transfer. Therefore, we have agreed the fol lowing;
• On occasions where a delayed response to an IFT request is advised the caller may wish to speak to the EOC Clinical Co-ordinator directly, or request a clinical review, for consideration of a Priority Response, Rapid Release or Drop and Go to facilitate a more prompt response.
Details of the request, including caller contact narne and number, and a brief surnrnary of any information pertinent to the request (such as treatment window or risk of deterioration) should he r@r.orded in CAD not@s ;ino escalated to the Clinical Co-ordinator throu8h norm;il escalation channPls.
• The EOC Clinicdl Co-ordinator is to review any such request as per norrnal process and decision making taking into account community risk and demand. Any decision must be communicated to the clinician making the IFT request and relevant dispc.1tch team as required. We continue to consider other options to support timely transfer of patients, including liaison with private ambulance providers. The challenges w ith ambulance transfer delays have been rPportPd to Spire Healthcare's Executive committee and we are being supported to seek solutions to this challenge at a national level. Kind regards
Director of Clinical Services
Sent To
- East of England Ambulance Service
Response Status
Linked responses
2 of 1
56-Day Deadline
28 Nov 2022
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 17 December 2021, I commenced an investigation into the death of Christina Avis RUSE aged 79. The investigation concluded at the end of the inquest on 22 August 2022. The medical cause of death was: 1a Multi-organ Dysfunction 1b) Hypovolaemic Shock 1c) Total Hip Replacement (Left) 14/12/21 1d) 2 Atrial Fibrillation, Ischaemic Heart Disease, Hypertension, Stroke, Myelofibrosis, Ex-Smoker, Chronic Kidney Disease. The conclusion of the inquest was: Misadventure.
Circumstances of the Death
Mrs Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer Mrs Ruse to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital. Her condition continued to deteriorate and Mrs Ruse died on 15 December 2021.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.