Patient was sent back to ambulance and died amid 'systemic failure'

A man died in hospital because of an ambulance delay due to a "systemic failure", a coroner's report has revealed. Robert Prowse died on September 19 last year at Royal Cornwall Hospital at Truro from sepsis. An inquest into the 86-year-old's death also heard how delays in ambulances getting to him and discharging him into A&E at Treliske prevented life-saving treatment.

The hearing held in Truro was told that on the day of his death Robert’s neighbour called 999 on his behalf after he was found breathing but not conscious, and it looked like he had had a seizure.

Following the 999 call South Western Ambulance Service Trust (SWAST) determined a Category 2 response requirement. Category 2 identifies potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. The national response time as set by the Department of Health is to attend Category 2 incidents within an average response time of 18 minutes, and at least 90 per cent of incidents within 40 minutes.

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The ambulance arrived on scene after a delay of three hours and 47 minutes from the time of the original 999 call. The ambulance arrived at Treliske but because of a shortage of beds in the hospital, Robert's transfer was delayed some more and instead of going to the emergency department (ED), he was taken from the ambulance to a triage centre adjacent to Treliske ED.

The inquest heard how it was such a busy time that there was crowding within the emergency department and some patients had to be placed in corridors.

The triage centre is known as the Rapid Assessment and Treatment Centre. There it was noted that Robert displayed evidence of sepsis but it was determined that his condition was not immediately life threatening. Robert was given fluids but not antibiotics and then returned to the ambulance parked outside ED.

He stayed there for almost 90 minutes when there is a target for crews to handover patients within 15 minutes of arriving at an emergency department. Robert was then subject to tests and sepsis was identified. He died two hours later before antibiotics could be administered.

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In a prevention of future deaths report, assistant coroner for Cornwall and the Isles of Scilly Guy Davies which he sent to Victoria Atkins, secretary of state for health and social care, he said the systemic failure was due to issues within healthcare services external to SWAST and despite an increase in resources it was not enough for the ambulance trust to overcome NHS failings as whole in terms of bed availability and social care packages available to help free up beds in wards.

Mr Davies said: "The court considered the findings in the SWAST Patient Safety Incident Investigation Report and an associated investigation conducted by the Healthcare Services Safety Investigation Branch (HSSIB). These investigations found that there is a direct link between patients waiting in the hospital for discharge to social care, and patients being cared for inside ambulances and emergency departments.

"In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated.

"This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge."

Mr Davies added that delayed discharge can lead to an increase in rehabilitation and care needs which in turn can have an impact on hospital capacity. He added: "It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments.

"A scientific study by the Royal College of Emergency Medicine discussed the adverse impact of crowding in ED. The study calculated the estimated number of excess deaths occurring across the United Kingdom associated with crowding and extremely long waiting times. The study showed that for every 72 patients waiting between eight-and 12-hours from their time of arrival in the Emergency Department there is one patient death.

"In September 2023 patients had spent a total of 14,327 hours in Treliske ED when it was clinically appropriate for these patients to be discharged or moved to a ward. This period of time is equivalent to closing 19 cubicles in Treliske ED for a whole month. Treliske ED has 26 cubicles."

Mr Davies added: "There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske.

"This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.

"Put simply, the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance."

A spokesperson for Cornwall and Isles of Scilly Integrated Care System said: “Our sincere condolences go to Mr Prowse’s family. We take every coroner’s report seriously as behind these statistics are people and families who have been affected, and we are profoundly sorry for their loss.

"We are working closely with health and care partners across Cornwall and the Isles of Scilly to identify and respond to the concerns raised in this report. We want to put into place local arrangements that ensure we continually improve our services with quality and patient safety at the heart.

“We are also addressing the complex issues highlighted in the coroner’s report to reduce waiting times, hospital admissions and increase hospital discharges, by providing more care and treatment locally."