John Seagrove, Pauline Humphris and Patricia Steggles
23 Nov 2023 · Coroner Andrew Cox · Cornwall and the Isles of Scilly
A similar concern from this report was raised again 8 times later. See the linked reports.
The coroner's concerns
1. ambulance delays and handover delays
“delays first in emergency ambulance response times and secondly, handing over the patient from the ambulance crew to hospital staff”
2. burn-out among healthcare staff
“burn-out' among paramedics, nurses and doctors”
3. staff recruitment shortages
“to recruit to vacant positions”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
Identical hazardConfidence 0.90 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Closely relatedConfidence 0.80 · moderate
This report
“During the course of these inquests, the evidence has revealed matters giving rise to concern.”
Later report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Identical hazardConfidence 0.92 · high
This report
“these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED”
Later report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Identical hazardConfidence 0.90 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“(2) Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Identical hazardConfidence 0.92 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Identical hazardConfidence 0.90 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Closely relatedConfidence 0.90 · high
This report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Later report
“On arrival at Royal Cornwall Hospital (RCHT), Mr [name redacted] spent a further 2 hours and 52 minutes before being handed over to the emergency department.”
Responses
2023-0468-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency.”