Bernard Gerrard
PFD Report
Partially Responded
Ref: 2018-0070
Coroner's Concerns (AI summary)
Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.
View full coroner's concerns
(1) There was a 10 hour vehicle response to attend to a Category 3 call. When the call was eventually upgraded to a Category 2 response, there was a further 50 minute delay. EMAS report that they cannot cope with the current demands placed on their service due to insufficient funding which is resulting in unacceptable vehicle response times
Responses
Action Planned
EMAS is negotiating with its Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20, and anticipates recruiting and training additional frontline operational staff and staff within the Emergency Operations Centre. They have already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April. (AI summary)
EMAS is negotiating with its Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20, and anticipates recruiting and training additional frontline operational staff and staff within the Emergency Operations Centre. They have already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April. (AI summary)
View full response
Dear Miss Syed Re: Report to Prevent Future Deaths: Bernard Leslie GERRARD (deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 9th March 2018 (received on 12th March 2018), bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Mr Bernard Leslie Gerrard. would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, matters arising from Coroners' Inquests which lessons can be learnt; including Prevention of Future Death Reports, are discussed within the Incident Review Group and Lessons Learned Group. This process has been applied to the Prevention of Future Deaths notice pertaining to the Inquest into the death of Bernard Leslie Gerrard_ Chief Executive: Richard Henderson Chairman: Pauline Emergency Care Urgent Care WVe Care Way Mary from Tagg
The MATTERS OF CONCERN specific to EMAS are as follows: There was a 10 vehicle response delay to attend Category 3 call When the call was eventually upgraded to Category 2 response, there was a further 50 minute EMAS report that cannot cope with the current demands placed on their service due to insufficient funding which is resulting in unacceptable vehicle response times set out below the actions that EMAS proposes to take and our response to HM Coroner's concerns as detailed in the PFD notice_ EMAS acknowledges its responsibility to enact a duty of care to all patients East Midlands Ambulance Service (EMAS) does not believe it is funded correctly to deliver the service our patients require: As a result the EMAS 2016/17, Urgent and Emergency Ambulance Contract; documented the agreement made between the Commissioners and ourselves to undertake jointly commissioned Independent Strategic Demand and Capacity Review, to understand the number of staff we require to deliver the nationally agreed standards. Within that agreement EMAS formally committed to the implementation of the utcome of the review, while Commissioners formally committed to support the implementation of the outcome: Due to the implementation of the national standards following the introduction of the Ambulance Response Programme in July 2017, the review concluded at the end of March_ The review has confirmed that EMAS has substantial resource gap and requires approximately 295 additional frontline operational staff and 48 additional staff to work within the Emergency Operations Centre to enable us to deliver the nationally defined performance standards. Negotiations are currently on-going with our Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20. We are expecting negotiations to be concluded in early May. In anticipation of the settlement EMAS has produced workforce and recruitment plan which will enable us to recruit and train these new staff so that become operational 2018/19 and the early part of 2019/20_ As part of this review the Trust has already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April. We operate 25 crews on duty across the region responding to patients who either require urgent admission to hospital, as determined by their general practitioner or other healthcare professional (HCP), or who have low acuity healthcare needs as assessed by our Clinical Assessment Team or frontline emergency crews_ hour delay: they they during
The crews are dispatched by a dedicated urgent care desk based in our Emergency Operations Centre and we have noted a positive impact on the times patient wait for an ambulance_ Each the crews are responding to over 90 patients; ensuring reach hospital safely and promptly. This has resulted at peak times in five hour reduction in the length of time patients are waiting for an ambulance to arrive The provision of the Urgent Care Team Service has reduced the number of patients requiring an A&E response which results in reduction in the number of patients experiencing prolonged wait that the measures set out in this letter provide you with the appropriate level of assurance in relation to EMAS' commitment to continuous improvement of services Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above.
The MATTERS OF CONCERN specific to EMAS are as follows: There was a 10 vehicle response delay to attend Category 3 call When the call was eventually upgraded to Category 2 response, there was a further 50 minute EMAS report that cannot cope with the current demands placed on their service due to insufficient funding which is resulting in unacceptable vehicle response times set out below the actions that EMAS proposes to take and our response to HM Coroner's concerns as detailed in the PFD notice_ EMAS acknowledges its responsibility to enact a duty of care to all patients East Midlands Ambulance Service (EMAS) does not believe it is funded correctly to deliver the service our patients require: As a result the EMAS 2016/17, Urgent and Emergency Ambulance Contract; documented the agreement made between the Commissioners and ourselves to undertake jointly commissioned Independent Strategic Demand and Capacity Review, to understand the number of staff we require to deliver the nationally agreed standards. Within that agreement EMAS formally committed to the implementation of the utcome of the review, while Commissioners formally committed to support the implementation of the outcome: Due to the implementation of the national standards following the introduction of the Ambulance Response Programme in July 2017, the review concluded at the end of March_ The review has confirmed that EMAS has substantial resource gap and requires approximately 295 additional frontline operational staff and 48 additional staff to work within the Emergency Operations Centre to enable us to deliver the nationally defined performance standards. Negotiations are currently on-going with our Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20. We are expecting negotiations to be concluded in early May. In anticipation of the settlement EMAS has produced workforce and recruitment plan which will enable us to recruit and train these new staff so that become operational 2018/19 and the early part of 2019/20_ As part of this review the Trust has already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April. We operate 25 crews on duty across the region responding to patients who either require urgent admission to hospital, as determined by their general practitioner or other healthcare professional (HCP), or who have low acuity healthcare needs as assessed by our Clinical Assessment Team or frontline emergency crews_ hour delay: they they during
The crews are dispatched by a dedicated urgent care desk based in our Emergency Operations Centre and we have noted a positive impact on the times patient wait for an ambulance_ Each the crews are responding to over 90 patients; ensuring reach hospital safely and promptly. This has resulted at peak times in five hour reduction in the length of time patients are waiting for an ambulance to arrive The provision of the Urgent Care Team Service has reduced the number of patients requiring an A&E response which results in reduction in the number of patients experiencing prolonged wait that the measures set out in this letter provide you with the appropriate level of assurance in relation to EMAS' commitment to continuous improvement of services Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above.
Sent To
- East Midlands Ambulance Service NHS Trust
- NHS Hardwick Clinical Commissioning Group
Response Status
Linked responses
1 of 2
56-Day Deadline
11 Aug 2018
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 14 December 2017 , an Inquest was opened into the death of BERNARD LESLIE GERRARD which was concluded on Wednesday 28th February 2018. The conclusion of the inquest was Natural Causes and the medical cause of death Ia Bronchopneumonia; Ib. Chronic Obstructive Pulmonary Disease, II. Left Fracture Neck of Femur: During proceedings, the Court heard Pathology evidence which confirmed that the bronchopneumonia caused by the underlying Chronic Obstructive Pulmonary Disease had resulted in Mr Gerrard's fall.
Circumstances of the Death
Mr Gerrard sustained injuries following an unwitnessed fall which occurred in his bedroom at around Spm on 28 November 2017 at the Milford Care Home where he resided. The care home buzzer was activated and the person that discovered Mr Gerrard, dressed his arm wound whilst waiting for other carers to attend. During this period, Mr Gerrard was not noted to be in any pain and there was no shortening of the limbs_ 111 was called to request the attendance of the District Nurse Mr Gerrard was reassessed by care home staff; moved off the floor into his armchair the hoist and was noted to sound breathless, also indicating to staff that his thigh was sore_ At 17.40, 111 called back and were informed of Mr Gerrard's breathlessness and his inability to stand. The care home were advised not to move Mr Gerrard further until the ambulance arrived on scene. According to the Care Home Investigation Report; they had contacted East Midlands Ambulance Service at 18.45, 20.45, 23.11, 03.47 before an ambulance finally arrived on scene at 05.30 on 29 November 2017. Mr Gerrard was transported to Royal Derby Hospital for treatment and care where investigations revealed a Left Fracture Neck Of Femur: Despite the best efforts of his treating clinicians, Mr Gerrard died on 02 December 2017 , The care home raised concerns that it had taken 12 hours for an ambulance to respond to Mr Gerrard. The Court heard evidence from an East Midlands Emergency Operations Centre Quality_Audit and Compliance Clinical Lead_that there_had been a 10 hour delay in noID being using responding to Mr Gerrard, stating the initial 111 referral call, had been time stamped at 18;19 and correctly categorised as a Category 3 response, meaning that a conveying vehicle should respond within 2 hours, in 9 out of 10 cases_ East Midlands Ambulance Service (EMAS) conceded at the latest an ambulance should have arrived on scene by 20.19. During evidence, EMAS explained that had received 3 calls from the care home; at 19.44, 20.58 and 23.07 and a clinician call back had been undertaken at 20.40 confirming there were vehicle shortages resulting in ambulance delays. During the call advised the care home to monitor the patient's condition and if there was any deterioration, EMAS should be re-contacted: At 03.10, EMAS correctly re-graded Mr Gerrard's condition to a Category 2 response, meaning that a conveying vehicle should respond within 18 minutes in 9 out of 10 cases_ to reflect his breathing deterioration. EMAS accepted that the upgraded response should have resulted in an ambulance arrival by 03.30 at the latest. An ambulance finally arrived on scene at 04.20, some 10 hours after receiving the initial 111 referral. The Category 3 and upgraded Category 2 responses both fell well outside of the National Response Standards required. EMAS stated that the reasons for the delays were that they had no available resources to deploy due to high Service demands_ EMAS accepted that the vehicle response time was unacceptable and stated that the Service couid not cope due to insufficient resources and lack of funding: EMAS stated that the period in question, they were holding three Category 2 calls and eleven Category 3 calls. When asked if these callers had also been waiting over 9 hours for a vehicle response, the reply was probably: EMAS went on to explain that received the third lowest amount of ambulance funding in the Country which had recently been debated at Parliamentary level and without further funding they could not function:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.