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 coroners sent prevention of future deaths (PFD) reports to health secretary Victoria Atkins in the wake of six deaths, expressing concerns over chronic problems that present a continuing risk to patients.
Two of the coroners warned that severe ambulance delays could return this winter. An emergency medicine consultant told one inquest that after improvements in response times over the summer, recent weeks had seen occasions when there were 15 to 20 ambulances waiting outside the emergency department.
One PFD report covered three deaths linked to ambulance delays affecting the South West Ambulance Service( SWASFT), with an eight-hour wait for an ambulance in one case and a 13-hour wait in another even though an ambulance would normally have been expected to arrive within 20 minutes.
All three inquests concluded within the last three weeks. The coroner, Andrew Cox, wrote in his PFD report: “I want to be clear that these three deaths are not isolated cases. They are just an illustration of the sorts of cases this area has dealt with regularly over the last two years or so.”
Warning that this winter would bring added pressures, he said he was hearing evidence of burnout among clinical staff, with difficulties filling hospital vacancies. “The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for the hospital or ambulance trust to fix on their own.
“It is for you and your department to take the action that is required to resolve the issues and to prevent future patients in the area from dying avoidable deaths,” he wrote to Atkins. “It is not for me as coroner to make recommendations on how you do that and so I leave that to you.”
An assistant coroner, Guy Davies, sent a PFD report to Atkins following two recent inquests also involving SWASFT. In one, an ambulance took more than eight hours to arrive. In the other, an ambulance took 13 hours to arrive, followed by a seven-hour handover delay.
“The root cause for delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes,” Davies wrote. The lack of social care capacity meant patients couldn’t be discharged from hospital, leading to a lack of hospital beds to transfer newly arriving patients into. This then left ambulances queuing outside the hospital to hand patients over, causing delays in ambulance response times.
Davies noted that a PFD report sent to the government in November 2022 had “raised the exact same concerns”, including the lack of adult care provision.
In its response to the Observer, the Department of Health and Social Care (DHSC) pointed to NHS data showing that ambulance handover delays of more than an hour were 28% lower last month than a year earlier. However, the Association of Ambulance Chief Executives has warned that handover delays have risen sharply in the run-up to winter.
The third PFD report followed the suicide in July of a man with long-term schizophrenia who had to be supported in the community with daily visits from mental health staff because no inpatient psychiatric beds were available when his symptoms deteriorated. It is the latest in a series of cases in Birmingham and Solihull in recent years that have highlighted the lack of psychiatric beds and other mental health services.
“The patient safety manager gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future,” coroner James Bennett wrote in his PFD report, sent to Atkins and local NHS bosses. “The issue of adequately funding psychiatric beds is a local and national issue.”
A DHSC spokesperson said: “Patients deserve access to the highest quality urgent and emergency care as quickly as possible, and our thoughts are with these individuals and their families.
“We are taking immediate action to improve access – our work delivered through the urgent and emergency care recovery plan is improving ambulance response times, with average responses to category 2 incidents in October almost 20 minutes faster compared to last year.
“Alongside record funding, we are providing £800m for this winter to support the NHS. We are also working to get 800 new ambulances on the road and create 5,000 additional permanent staffed hospital beds to further reduce waiting times.”