Dennis Harry
22 Sept 2024 · Coroner Guy Davies · Cornwall and Isles of Scilly
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. excessive ambulance delays
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays. This creates a risk of future systemic failures causing excessive ambulance delays.”
2. lack of single organisation responsibility for social care provision
“There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.”
3. absence of overarching organisation for patient safety risk from ambulance delays
“There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
This report
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
Identical hazardConfidence 0.90 · high
This report
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
Later report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital, there being a direct link between inadequate social care provision and ambulance delays.”
Identical hazardConfidence 0.90 · high
This report
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
Later report
“The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS.”
Responses
2024-0508-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action
“making space for a Clinical Decision Unit model, for patients who need more clinical care but don't need to be admitted to hospital”