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Coroners in England and Wales sent 109 warning letters to the government and health bodies in 2023 highlighting long NHS waits, staff shortages or a lack of NHS resources, the BBC has found.
The number of cases identified that were linked to NHS pressures was the highest in the past six years.
Prevention of future death reports (PFDs) are sent when a coroner thinks action is needed to protect lives.
The government says it “responds to, and learns from, every report”.
Coroners are specialist judges in charge of inquests, which investigate the circumstances of deaths that appear to have an unknown, violent or unnatural cause.
The BBC combed through hundreds of PFD reports written after inquests to find cases linked to long NHS waits or pressure on the health service.
The 109 identified in 2023 compared with 58 in 2019, and 49 in 2018, before the pandemic. The BBC also found 62 cases in 2022, 45 cases in 2021, and 37 in 2020, when it was more likely Covid may have affected the number of inquests held and reports written.
‘Firefighting’
William Gray was fond of maths and wanted to be a doctor when he grew up. He died after a life-threatening asthma attack, aged 10.
In October 2020, he was struggling to breathe in the middle of the night. His mother gave him CPR and he was rushed to Southend Hospital by ambulance, only to be discharged four hours later.
In the months that followed, his family tried and failed to get the specialist help they needed.
Some changes were made to William’s inhaler but, after a consultant appointment, he was “lost to follow-up” at the hospital, his inquest heard. His GP did not prescribe continuing preventative medication to control his condition.
At the time of his admission, there was a single nurse working in the children’s asthma and allergy service in south-east Essex, increasing to two nurses in November 2020.
Staff had a caseload of 2,000 children and demand was growing, with referrals up 75% between 2018 and 2023.
“Nurses were being asked to provide the impossible,” coroner Sonia Hayes said at William’s inquest. Staff were “firefighting” and the service was “ludicrous”.
On 29 May 2021, William had another severe asthma attack. This time doctors could not save him and he died in hospital.
“It’s been horrendous for us, having to try to adjust to life without him,” said his mother Christine Hui.
“I just don’t want any other family to go through what we’ve been through.”
After William’s inquest in December 2023, the coroner wrote a strongly worded PFD report to Health Secretary Victoria Atkins and the NHS bodies responsible for his care.
The children’s asthma service “remains under-resourced”, William’s death was “avoidable”, and better treatment “would and should” have saved his life, the coroner added.
In response, Essex Partnership University NHS Trust said it had recruited three more asthma nurses through a pilot scheme, although it had requested funding for eight.
“Since this tragic incident, our specialist community asthma services have been remodelled to enhance the care we provide,” a spokeswoman added.
Mid and South Essex NHS Trust, which runs Southend Hospital, also said it had introduced “numerous changes” to improve patient care.
Prevention of future deaths
About 35,000 inquests take place in England and Wales each year. In a fraction of those – about 450 – the coroner writes a PFD, or Regulation 28, report.
The BBC analysed 2,600 PFDs – and supporting documentation – sent between 2018 and 2023.
The proportion of the total number of PFD reports that referenced an NHS resource issue rose to one in five in 2023, from one in nine in the two years before Covid.
Of the 540 reports written last year, 109 were found that highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners.
Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services.
That included the case of Shaun Parks, 52, who was driven to Doncaster Hospital in December 2022 with chest pains. He arrived at midnight and waited in the A&E department for more than an hour before being seen.
“Within seconds of the [ECG] machine being hooked up to him, the nurse ripped off a piece of paper and ran,” said his wife Karen.
“She came back through and said, ‘Mr Parks, you’re having a heart attack, we need to get you through to the resuscitation area right now’.”
Shaun was stabilised and told he needed to be moved to a specialist unit in Sheffield, but his inquest heard high demand and insufficient staffing levels meant the ambulance, which should have arrived in 18 minutes, took more than three hours to pick him up from Doncaster.
Shaun died in hospital later that morning.
In a PFD sent to the Department of Health in December 2023, the coroner raised concerns about the “significant delay” ambulances were facing offloading patients, and noted that Mr Parks had “deteriorated during his time at Doncaster Royal Infirmary”.
“If he had got there earlier, granted it might have been the same outcome, but he would have had more of a chance of survival,” said Karen.
“I loved Shaun to bits. I loved the ground he walked on. It shouldn’t happen in this day and age.”
After his inquest, NHS West Yorkshire Integrated Care Board, which commissions ambulance services in the region, said it had been investing in more staff and vehicles, though it accepted there were “ongoing challenges” with response times.
As in Shaun’s case, it can take months, or even years, for an inquest to take place. The latest figures, for 2022, show it took 30 weeks on average from the date someone died until the process was complete and a PFD report could be sent.
“Reading the reports is heartbreaking, and our thoughts are with the families and loved ones of all those who died,” said Dr Adrian Boyle, the president of the Royal College of Emergency Medicine.
“The link between the issues highlighted and the pressures currently being experienced by our urgent and emergency care system is stark. This is also supported by scientific evidence which shows the single leading theme is delay.”
‘Into the ether’
NHS trusts, government departments and other organisations have a mandatory duty to respond to PFD reports, but any changes recommended by the coroner are not legally enforceable.
Deborah Coles, the director of the charity Inquest, told a parliamentary hearing last month there was a danger reports could simply “disappear into the ether”, with the same mistakes repeated in the future.
Inquest, and law firms representing bereaved families, are calling for the creation of a new independent body to audit hundreds of reports each year, and make sure recommendations are implemented.
In a statement, the Department of Health and Social Care in England said it learnt from every PFD report.
“Our £1bn urgent and emergency care plan sets a clear vision for how we are working to cut waiting times,” said a spokesman, alongside a £2.4bn plan to “train, retain and reform” the NHS workforce.
An NHS England spokeswoman added: “Despite ongoing pressures from record demand and high bed occupancy, the NHS continues to focus on improving patient flow, ensuring patients are seen by the most appropriate services and minimising delays.”
Sixteen of the 109 PFDs linked to NHS pressure in 2023 were written by coroners in Wales. A spokesman for the Welsh government said it had a “clear urgent and emergency care improvement plan in place, supported by an extra £50m over the past two years”.
Methodology
The BBC analysed 2,600 PFD reports written between 2018 and 2023, and published on the Ministry of Justice website.
Many reports are complex, with multiple causes of death and “matters of concern” listed. Whether a coroner decides to issue a report, and the level of detail they choose to include, varies.
Cases were identified that clearly referred to pressure on the health service, a shortage of medical staff or a lack of NHS resources.
Reports that met the criteria were highlighted and reviewed by more than one person on the BBC team.
Additional reporting by John Walton, Aidan McNamee and Joe McFadden.
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