Coroners have written damning warnings to the government over persistent crises in the NHS after multiple inquests into patient deaths following ambulance delays – and the latest in a string of cases in Birmingham linked to insufficient mental health beds.
Three medical examiners submitted reports to the health secretary, Victoria Atkins, regarding steps to prevent future deaths (PFD) after six individuals passed away. They highlighted ongoing issues that pose a potential danger to patients.
Two coroners cautioned about the potential for prolonged ambulance wait times this winter. A consultant in emergency medicine stated during an investigation that, despite progress made in response times during the summer, there have been instances in recent weeks where up to 20 ambulances have had to wait outside the emergency department.
A recent PFD report discussed three fatalities associated with delayed ambulance response times from the South West Ambulance Service (SWASFT). In one instance, there was an eight-hour delay for an ambulance, and in another case, a 13-hour delay, despite the expected arrival time being 20 minutes.
The three investigations were completed in the past three weeks. In his PFD report, the coroner, Andrew Cox, stated: “I want to emphasize that these three fatalities are not unique occurrences. They are merely an example of the types of cases that have been consistently addressed in this region over the past couple of years.”
He cautioned about the upcoming winter causing more strain and mentioned reports of exhaustion among medical personnel, as well as struggles to fill hospital positions. He stated that the issues were ingrained in the system and cannot be solved by individual healthcare workers or institutions alone.
“It is the responsibility of you and your department to take appropriate measures to address the issues and prevent avoidable deaths of future patients in the area,” he wrote to Atkins. “As a coroner, it is not my role to make recommendations on how you should accomplish this, and thus I will leave it in your hands.”
Guy Davies, an assistant coroner, sent a PFD report to Atkins after two recent inquests that also involved SWASFT. In one case, it took more than eight hours for an ambulance to arrive. In the other case, an ambulance arrived after 13 hours, followed by a delay of seven hours for handover.
Davies discovered that the primary reason for delays was the insufficient availability of social care services in Cornwall, including care packages and care home beds. The limited capacity of social care resulted in patients being unable to be discharged from the hospital, which led to a shortage of beds for new patients. This resulted in ambulances having to wait outside the hospital to transfer patients, causing delays in ambulance response times.
In November 2022, Davies mentioned that a report from PFD was submitted to the government, which highlighted the identical concerns, such as the inadequate provision for adult care.
The DHSC responded to the Observer, citing NHS data that showed a 28% decrease in ambulance handover delays lasting over an hour compared to the previous year. The Association of Ambulance Chief Executives has cautioned that handover delays have significantly increased leading up to winter.
The most recent PFD report pertained to the death by suicide in July of an individual with chronic schizophrenia. Due to the unavailability of inpatient psychiatric beds, this individual had to rely on daily visits from mental health personnel while living in the community. This case is one of many in Birmingham and Solihull that have brought attention to the inadequate provision of psychiatric beds and other mental health resources in recent years.
The patient safety manager provided proof that the ongoing issue of insufficient psychiatric bed availability has not been addressed, and there is a real danger of a similar problem occurring with another patient in the future. Coroner James Bennett stated in his report, which was sent to Atkins and local NHS leaders, that the funding for adequate psychiatric beds is a concern both locally and nationally.
A representative from the DHSC stated: “It is vital that patients have swift access to top-notch urgent and emergency care, and our sympathies go out to these individuals and their loved ones.”
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We are quickly working to enhance accessibility. Our efforts, as outlined in the urgent and emergency care recovery plan, have resulted in improved ambulance response times. In October, our response time for category 2 incidents was almost 20 minutes faster than the previous year.
“In addition to receiving a historic amount of funding, the NHS will also receive an additional £800m for the winter season. We are actively working towards increasing the number of ambulances on the road by 800 and creating 5,000 more permanent hospital beds in order to decrease waiting times.”
Source: theguardian.com
