A man tragically lost his life in hospital following a ‘grossly excessive ambulance delay’, as per a report. Dennis Richard Harry passed away on January 10, 2023 at Royal Cornwall Hospital in Truro due to heart disease and a Covid-19 infection he contracted while in the hospital.
An inquest into his death revealed 87-year-old Mr Harry had to endure a staggering wait of 15 hours and 35 minutes for an ambulance to arrive at his Helston home, followed by another three hours and 14 minutes in the ambulance parked outside the emergency department before being admitted. The hearing, held in Truro on September 12, was informed that such lengthy ambulance waits are a result of a ‘systemic failure’ within the NHS, with ambulances forced to queue outside the region’s main hospitals for hours until beds become available.
It was further noted these delays are due to inadequate patient flow in and out of hospitals, with many fit patients remaining in hospital as they cannot be discharged due to a lack of social care, primary health care support or community health care provision.
In a grim report sent to Wes Streeting, Labour’s Secretary of State for Health and Social Care, detailing systemic healthcare failures that potentially contributed to Mr Harry’s death, Assistant Coroner for Cornwall and the Isles of Scilly, Guy Davies, said: “Dennis died from Covid 19 and heart disease following a grossly excessive ambulance delay of 18 hour and 50 minutes, this delay being attributable to a systemic failure related to the whole system of health and social care, which was possibly causative of death.”
The inquest heard staggering figures highlighting how on December 20 2022, when Mr Harry’s family called 999, up to 18 ambulances were seen queuing outside Treliske’s emergency department (ED). By 8am the next morning, 56 patients swamped the ED, designed for 44, with 11 ambulances waiting outside, reports Cornwall Live.
Additionally, during December 2022, discharged patients from the ED had to wait over 20,144 hours for beds or transport, effectively shutting down the equivalent space of 27 cubicles within the department. This bottleneck suggests more than half the available space in the ED was consistently occupied by stagnant patient traffic throughout the month.
The inquest heard Treliske hospital was frequently missing its four-hour target for moving patients out of the ED. with Mr Davies noting in his report that studies indicate the standardised mortality rate begins to climb after a patient has been in the ED for five hours. They also found that beyond six to eight hours, there is one additional death for every 82 patients delayed. On the day Mr Harry’s family called 999, Treliske had 120 stranded patients, which exceeded 20 per cent of the hospital’s bed capacity.
In the report, datedSeptember 22 this year, Mr Davies said: “The court found significant correlation between delayed discharges, handover delays and delays in response times. On this basis, the court found there was a direct connection between the ambulance delay experienced by Dennis and inadequate social care provision, community hospital provision and primary healthcare support leading to delayed discharges from hospital.
“The connection between delayed discharges and ambulance delays and the associated risks has been referred to in reports from Southwest Ambulance Service Trust (SWAST) and the Health Services Safety Investigations Body (HSSIB). The court found that the state knew or ought to know of the risks.”
Mr Davies highlighted the grim reality that this situation is not unique to Cornwall but is a nationwide issue. In Cornwall, the crisis is exacerbated by a 10 per cent vacancy rate in social care jobs. He emphasised the need for a comprehensive system review to minimise patient harm.
He added: “SWAST and RCHT do not have control over the services primarily responsible for ambulance delays, namely social care provision, primary healthcare provision and community hospital provision. They are unable to influence the whole system and, therefore, carry risks that they cannot wholly mitigate or manage.
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays. This creates a risk of future systemic failures causing excessive ambulance delays.”
“There is no single organisation with responsibility to ensure that the provision of social care is sufficient to avoid delayed discharges leading to ambulance delays. The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market.
“There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays.” It was the second such PFD report Mr Davies wrote in as many weeks about the systemic failures of the NHS. Another inquest last month heard how ambulance delays were so bad, it contributed to holidaymaker Kevin George Woods not receiving the medical care he needed fast enough in January this year.