Kyriacos Athanasis
6 Jan 2023 · Coroner Catherine Wood · Norfolk
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance transfer to emergency department
“Evidence given at the inquest revealed that there was a delay in Mr. [name redacted] being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into”
2. delayed diagnosis of cervical fracture
“In this instance the mechanism to undertake a safety check was not sufficient to reveal the extent of the injuries Mr. [name redacted] had sustained, and this meant there was a delay in diagnosing him with his unstable cervical fracture”
3. overcrowded emergency department
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave”
4. hospital overcapacity
“Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40)”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department.”
This report
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave.”
Identical hazardConfidence 0.90 · high
This report
“(1) Evidence given at the inquest revealed that there was a delay in Mr. [name redacted] being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into.”
Later report
“1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Closely relatedConfidence 0.90 · high
This report
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave.”
Later report
“There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department”
Responses
2023-0007-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 3 February 2023
“the Integrated Care Board (ICB) responsible for JPUH, Norfolk and Waveney ICB, provided a comprehensive response on 3 February 2023 which included information on the improvements being made locally, and details of a serious incident investigation report following Mr [name redacted]' death.”
2023-0007-Response-from-Norfolk-and-Waveney-Integrated-Care-Board.pdf ↗· The Norfolk and Waveney Integrated Care Board