John Winsworth
29 Sept 2023 · Coroner Jacqueline Lake · Norfolk
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed ambulance response
“The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”
2. delayed hospital admission
“The ambulance arrived at the Norfolk and Norwich University Hospital at 10.52 hours and Mr [name redacted] was not able to be admitted to Accident and Emergency Department until 14.42 hours; over 3 hours following admission, due to pressure on the hospital.”
3. delayed ambulance attendance
“Considerable delays in attendance by EEAST (East of England Ambulance Service Trust) to calls continues.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”
This report
“The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”
Identical hazardConfidence 0.90 · high
This report
“The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”
Later report
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Responses
2023-0357-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“the EEAST have taken the following actions taking to work with the integrated care system to reduce the impact of delays and reduce patient harm, including but not limited to: - EEAST are a member of the "Front Door Group" looking to improve arrival to handover times. This is chaired by the Deputy Director for Intensive Support from the NHSE/I team. EEAST have shared good practice from West Suffolk and Colchester Hospitals within the group, which is attended by all Acutes in the area. EEAST have”