Grenville Wait

PFD Report All Responded Ref: 2022-0195
Coroner Chris Morris
Coroner Area Manchester South
All 1 response received
Coroner's Concerns (AI summary)
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –

1) Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken via its patient safety plan to manage and respond to demands on its service, it is a matter of concern that target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust’s average response time for a category 2 call was 50 minutes with the response time to 90% of all relevant incidents of 1 hour and 48 minutes.
Responses
Department of Health and Social Care Central Government
Action Taken
The Department of Health and Social Care acknowledges concerns about ambulance pressures and details significant ongoing actions, including an additional £3.3 billion investment, increased bed capacity, a £500 million discharge fund, and targeted support for hospitals to improve ambulance handover delays and expand the paramedic workforce. (AI summary)
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Dear Mr Morris, Thank you for your letter of 24 June 2022 to the then Secretary of State, the Rt Hon Sajid Javid, about the death of Grenville Wait. I am replying as Minister with responsibility for Health and Secondary Care and thank you for the additional time to respond. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Wai(s death, and I offer my sincere condolences to his 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. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). The Government is committed to supporting the ambulance service to manage the pressures i_t is facing, ensuring that people receive the treatment that they need when they need it. A range of measures are in place to improve ambulance performance. This will be supported by the government investing an additional £3.3 bilfion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will also set out detailed recovery plans in the new year, including plans to improve ambulance response times and improve A&E waiting times. The NHS has set out a plan to substantially increase capacity and resilience this winter. Bed capacity will be increased by the equivalent of at least 7,000 general and acute beds, alongside a £500 million Adult Social Care Discharge Fund, helping improve patient flow through hospital and reduce long waits in handing ambulance patients to A&E, getting ambulances swiftly back on the road. Further winter actions include establishing 24/7 System Control Centres in all local systems to better manage demand at a system level, and expanding falls response services right across the country, which will see local teams sent to help people who have fallen in their home or in care homes, rather than unnecessary trips to hospital. Addressing ambulance handover delays is also a key priority. NHS England is providing targeted support to some of the hospitals facing the greatest delays in the handover of ambulance patients into the care of hospitals, helping them to identify short and longer-term interventions to improve delays and get ambulances swiftly back out on the road. This is

, alongside a new national Winter Improvement Collaborative programme to help other trusts identify the root causes of handover delays and implement best practice. NHS England has allocated £150 million of additional system funding for ambulance service pressures in 2022/23, supporting improvements to response times through additional call handler recruitment, retention, and other funding pressures. This is alongside £20 million to upgrade the ambulance fleet. The Government has also made significant investments in the ambulance workforce and the number of NHS ambulance staff and support staff has increased by almost 40% since April
2010. Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service. I hope this response is helpful and you are assured that we will continue to work with the NHS to ensure the ambulance service has the support it needs to deliver for patients, both through winter pressures and beyond. Thank you for bringing these concerns to my attention.
Sent To
  • Department of Health and Social Care
Response Status
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 3rd February 2022, I opened an inquest into the death of Grenville Wait who died on 6th November 2021 at home, aged 83 years. The investigation concluded with an inquest which I heard on 22nd June 2022, and which concluded that Mr Wait had died as the consequence of an accident.
Circumstances of the Death
Mr Wait fell whilst out shopping on 2nd November 2021. He was taken to hospital where a fractured sternum was diagnosed. Mr Wait was discharged home with advice about taking regular analgesia and a plan to follow-up with a fracture clinic appointment. On 6th November 2021, a family member found Mr Wait deeply unconscious in bed with altered breathing. A 999 call was made, and an emergency ambulance dispatched by way of a category 2 response, the call having been incorrectly coded as a category 2 rather than a category 1 call. The ambulance arrived around 70 minutes after the time of the original 999 call, outside of the target range for category 2 calls. Around the time of the ambulance crew’s arrival, Mr Wait went into cardiac arrest and could not be resuscitated. A post mortem examination determined Mr Wait died as a consequence of:­ 1a) Pneumonia on background of fractured sternum
2) Ischaemic heart disease.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Ambulance data on conveying deceased
Fuller Inquiry
Ambulance Handover Delays
Hepatologist Oversight and Fibroscan Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Specialist Hepatology Centre Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Uncertainty About Fibrosis
Infected Blood Inquiry
Delayed Recognition of Deterioration
Fibroscan for Liver Imaging
Infected Blood Inquiry
Delayed Recognition of Deterioration
Consultant Hepatologist Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Commissioning Hepatology Services
Infected Blood Inquiry
Delayed Recognition of Deterioration

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.