Samuel Garner
27 Jul 2020 · Coroner Alison Mutch · Greater Manchester South
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. overcrowded emergency department during winter pressures
“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 had been typical of the picture in both the preceding and following weeks due to winter pressures/demands”
2. inadequate space leading to treatment in corridor and movement between bays
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED. This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need”
3. delayed chest drain procedure
“He waited a number of hours for his chest to be drained (after it was identified that was what was required) due to competing demands on clinical staff. He was in significant distress whilst waiting”
4. delayed transfer to surgical ward
“It was identified at an early stage that he would need a surgical bed and his care would be optimised in such a setting. There was a significant delay in moving him from the Emergency Department to a surgical ward due to lack of bed capacity within the Trust”
Linked reports
Closely relatedConfidence 0.85 · high
This 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.”
Later 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
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED.”
Later report
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so”
Identical hazardConfidence 0.90 · high
This report
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED.”
Later report
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so.”
Responses
2020-0145-Response-from-DHSC_Redacted.pdf ↗· Department of Health and Social Care
Stated action
“We must do all we can to learn from what happened to Mr [name redacted] and improve the safety and quality of NHS care and I expect the Stockport NHS Foundation Trust and its local system partners to reflect carefully on the findings of your investigation.”
2020-0145-Response-from-GMHSCP_Redacted.pdf ↗· Department of Health and Social Care
Stated action · April 2022
“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go”