Coroner says care crisis and ambulance delays in Cornwall are causing deaths

Ambulances waiting outside Royal Cornwall Hospital in July 2022.
Delays in ambulance times has contributed to patient's deaths

A coroner in Cornwall has said delays in ambulances reaching patients and hospital bed-blocking have contributed to or even caused patient deaths.

Senior Coroner Andrew Cox has now written to the Health Secretary about his concerns about the crisis in the social care sector.

He spoke about three people in the county where delays in ambulances reaching them had caused or contributed to their deaths.

One of them was Tony Reedman, from Norfolk, who had to wait more than two hours for an ambulance after having a stroke while on holiday in Cornwall. He died in hospital days later.

Mr Cox also referenced the deaths of David Morganti and Winnie Barnes-Weeks, saying delays in ambulances reaching them and their subsequent admission to hospital "either caused or contributed to their deaths".

He also spoke of a fourth inquest, into the death of Robert Conybeare. He died after suffering a fall in the hospital at a time when he was fit to be discharged but there was no suitable social care support in place.

Kate Shields, Chief Executive Officer of Cornwall and Isles of Scilly Integrated Care Board said bodies across Cornwall were working together to improve patients' experience of the health and care system.

Mr Cox has now written a Preventing Future Deaths report to Health Secretary Steve Barclay.

In it, he said: “All of the cases listed above have recurring themes, being long delays in ambulance attendance and/or long delays in admission into the only acute hospital in the coroner area, Royal Cornwall Hospital.

“It is appropriate to record both that these are only a selection of the inquests of this nature already heard and that there are a number of inquests of a similar nature still to be heard.”

Mr Cox said he had been told by the medical director at the South West Ambulance Service Trust that delays were being caused by ambulances being in the “wrong place at the wrong time”.

Mr Cox added: “When they are required for emergency responses, they are parked outside Royal Cornwall Hospital with patients in the back for extended periods.

“On occasions this summer and autumn, there have been queues of over 20 ambulances outside the emergency department and delays have been longer than a paramedic’s shift.”

The coroner said the Royal Cornwall Hospital’s medical director had told him there had been at times the equivalent of five wards of patients fit for discharge, but they could not leave due to problems with the social care sector.

He wrote: “This appears to be borne out by the evidence I heard during the inquest into the death of Mr Conybeare."

The report gives the Department of Health and Social Care until January 10 to respond to the coroner’s concerns.

“My central concern is how the delays that are currently manifest can be mitigated in the intervening months, particularly given the likely increase in demand for ambulances/hospital admissions during the winter months,” Mr Cox wrote.

“While there is an obvious need to discharge medically fit patients from Royal Cornwall Hospital, this has to be done in a controlled and manageable fashion.

“GP representatives have drawn to my attention the extreme pressures primary care is currently under.

“Without more, it would seem to serve little purpose simply to transfer patients from one part of the system that is struggling to cope to a different part of the system that is equally challenged.

“Similarly, it will not benefit patient health to discharge a patient from a hospital to a residential home that does not have an appropriate level of staffing.

“All that will happen is that the patient will inevitably become de-conditioned, their illnesses will worsen and the result will be that they are likely to require re-admission.”

Kate Shields, Chief Executive Officer Cornwall and Isles of Scilly Integrated Care Board, said: “We extend our sincere condolences to the families of the patients whose deaths are referenced in the coroner’s report."

In a statement also released in partnership with Cornwall Council, Royal Cornwall Hospitals NHS Trust and South Western Ambulance Service, she added: “The report highlights the complex pressures on all parts of our health and care system that our staff are working tirelessly to resolve. 

"None of us want anyone to experience long waits for the care they need in the community, or in hospital.

“We have recently introduced new ways of working with the aim of reducing delays in patients’ journeys from their admission through to discharge in both our acute and community services.  

"These changes have resulted in some improvement in ambulance response and handover times in Cornwall but we will continue to focus our efforts until we are confident all patients get timely access to care.

“Cornwall Council has pledged significant investment in adult social care with plans in place to develop new capacity across a range of services and providers, including 750 units of extra care (supported accommodation) and the recommissioning of care home capacity that has closed.

“There is more to do and if we can sustain and build on the progress we are making, we will be able to provide the timely and safe care we want for our communities”.

A Department of Health and Social Care spokeswoman said: “Each of these four deaths is a tragedy and our sympathies are with the families affected.

“We have received the prevention of future deaths report and will be responding to the coroner in due course.

"We have prioritised health and social care in the autumn statement, with an additional £6.6billion available over the next two years, to tackle the backlog, speed up discharge and ensure patients are getting the care they deserve quickly.

“This is on top of an additional £500million to free up hospital beds by discharging patients into social care more quickly.

“The Chancellor also announced the Government will set out measures to support and grow its workforce, including publishing a comprehensive workforce strategy next year with independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in five, 10 and 15 years’ time, taking full account of improvements in retention and productivity.”

  • Want a quick and expert briefing on the biggest news stories? Listen to our latest podcasts to find out What You Need To Know.