‘Risk of future deaths’: coroner issues rare warning to health secretary over hospitals crisis

A coroner has urged the health secretary to take action to prevent needless deaths after a woman died of heart failure following a four-hour wait in the back of an ambulance.

Lyn Brind, 61, was taken to the Queen Elizabeth Hospital (QEH) in King’s Lynn, Norfolk, with chest pains and low blood oxygen levels but could not be admitted because the hospital had “no space”. Instead she remained in a queue of ambulances outside A&E without a timely diagnosis or treatment and where warning signs about her condition were missed.

It was only after four hours and 25 minutes of waiting that she was transferred to a ward, by which time she was “agitated and short of breath”. She was placed on life support but died 22 minutes later.

Brind’s family believe the grandmother of four, a former dinner lady from the town, “might still be alive today” had she been admitted more swiftly. “She wasn’t given a chance,” her partner of 38 years, Richard Bunton, said.

After an inquest earlier this month into Brind’s death in May 2022, the senior coroner for Norfolk, Jacqueline Lake, took the unusual step of writing to England’s health secretary, Steve Barclay, to raise concerns about the NHS and social care.

She warned that others could die in similar circumstances unless action was taken. “I believe you have the power to take such action,” Lake wrote in a prevention of future deaths report published last week.

The coroner said that the QEH was regularly overwhelmed, with “too many patients in the emergency department” and a lack of social care in the community preventing people from leaving hospital.

At the time of Brind’s death, approximately seven ambulances were waiting to offload patients outside A&E, she said – a number that had risen to 17 commonly queueing outside the department at the time of the inquest earlier this month. There were also 140 beds occupied by patients who were “medically fit” but could not be discharged due to a lack of social care places, Lake wrote.

The report highlighted failings in Brind’s care, including that observations were not taken regularly in accordance with East of England Ambulance Service Trust guidance and that when they were taken, her deteriorating condition was not flagged to the hospital’s ambulance navigator, who assesses priority for beds. Brind, who had multiple medical conditions including diabetes, was also not assessed by a senior doctor from the hospital within an hour, in accordance with hospital protocol.

But the coroner said evidence indicated the problem was “much wider and more complex” than a single NHS trust and that action was needed at government level.

The warning comes amid reports of record NHS backlogs and treatment delays. Figures released last week by the Association of Ambulance Chief Executives show an estimated 57,000 patients experienced potential harm due to delays in ambulance handovers in December, with 6,000 of those experiencing “severe harm”.

The Royal College of Emergency Medicine has estimated that there are 300-500 excess deaths across the UK each week due to overcrowding and long waiting times in emergency departments. NHS England has said it does not recognise those figures.

The government is yet to formally respond to the report on Brind’s death but has a duty to by 13 March. A Department of Health and Social Care spokesperson said it was taking “urgent action” to improve hospital backlogs, including “investing £250m to free up hospital beds, reduce pressures on A&E and unblock delays in handing patients over from ambulances”.

Related: Up to one in three English hospital beds occupied by patients fit for discharge

It previously announced a £500m discharge fund and said it had created the equivalent of 7,000 more hospital beds. Hours lost to ambulance handover delays fell in the week to 22 January to the lowest this winter, a spokesperson added.

This is not the first time a coroner has raised the alarm over ambulance delays. In November, Andrew Cox, the senior coroner for Cornwall, wrote to Barclay to flag similar concerns about the crisis in social care leading to a shortage of hospital beds. He cited four cases where ambulance delays and hospital overcrowding had caused or contributed to the death of patients in the county.

Helen Blanchard, interim chief nurse at QEH, King’s Lynn, said the trust had learned lessons from Brind’s death and had “implemented the NHS care standards for patients waiting in ambulances, including working with ambulance staff to ensure patients are still seen by a senior doctor if they cannot immediately come into the department”, and completing 30-minute observations.

East of England ambulance service said it had met the hospital’s serious incident team to discuss ways to “help prevent this from happening again”. “The coroner has written clearly of the pressures the NHS was under at this time and subsequently, which have resulted in handover delays at hospital emergency departments,” a spokesperson said.