Kenneth Heard
23 Nov 2023 · Coroner Guy Davies · Cornwall and the Isles of Scilly
This report repeats 1 earlier warning, and was raised again 10 times later. See the linked reports.
The coroner's concerns
1. ambulance delay
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust)”
2. delayed patient handover
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”
3. handover delay
“On 10 July 2022 there were over 403 hours of ambulance time lost at Treliske Hospital with the average handover taking seven hours and 34 minutes per patient. At Derriford Hospital, there were over 201 hours lost, with the average handover taking three hours and 28 minutes”
4. response time increase
“Evidence heard at [the deceased]'s Inquest indicates that there is a strong relationship between the hours lost due to handover delays and the response times being delivered by SWAST. Data shows that as the time lost to handover delays has increased, the response times have increased at a similar rate. In [the deceased]'s case this relationship between response and handover is clearly revealed. The ambulance response time to [the deceased] was eight hours and 10 minutes. The concurrent average handover delays being”
5. ongoing handover delays
“Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro”
6. lack of social care
“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. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department.”
Closely relatedConfidence 0.90 · high
This report
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”
Later report
“handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available)”
Identical hazardConfidence 0.90 · high
This 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.”
Later 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
“Evidence heard at [the deceased]'s Inquest indicates that there is a strong relationship between the hours lost due to handover delays and the response times being delivered by SWAST.”
Later report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Closely relatedConfidence 0.90 · high
This report
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”
Later report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing”
Identical hazardConfidence 0.90 · high
This report
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall:”
Later report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Identical hazardConfidence 0.90 · high
This 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.”
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.”
Identical hazardConfidence 0.95 · high
This 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.”
Later report
“(1) 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
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”
Later report
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes.”
Closely relatedConfidence 0.90 · high
This 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.”
Later report
“The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.”
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
Responses
2023-0473-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · March 2025
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”