NHS waiting times, staff shortages and service backlogs have been flagged as concerns in relation to dozens of patient deaths across England and Wales since the start of last year, the Observer can reveal, with coroners facing a succession of inquests concerning ambulance delays.
Coroners issue prevention of future deaths reports (PFDs) when they believe preventive action should be taken, and send them to relevant individuals or organisations, which are expected to respond.
Among 55 cases identified by the Observer are 24 patient deaths where coroners raised concerns about ambulance delays – all of them occurring before this winter’s ambulance crisis, when response times rocketed to their worst-ever levels.
Wes Streeting, shadow health and social care secretary, said: “The NHS is in the biggest crisis in its history – and the crisis has a cost in lives. Patients are waiting for far longer than is safe, with terrible consequences.”
A PFD report published this month detailed how a woman died last summer after waiting nine hours for an ambulance when she fell at home. She was lying on the floor, unable to use the toilet, with her breathing deteriorating.
She then had to wait three more hours to see a doctor at Tameside General Hospital’s emergency department before dying of Covid pneumonia.
“The inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at emergency departments across Greater Manchester to offload patients,” coroner Alison Mutch wrote in her report. “The evidence before the inquest was that the delay on the day [the deceased] was waiting for an ambulance was not unusual and still remained the case on the day of the inquest.”
In another case, a Cardiff woman with a disability died in June 2021 after several calls to the ambulance service over two hours proved fruitless as no ambulance was available.
The report said that when asked by a call responder how much pain she was in on a scale of one to 10, she was “screaming in agony” and responded “11”. Her husband testified that the call responder said that “if [she] could scream then she was not a priority”. Within an hour of the call, she died “without any emergency support and in agony”.
The coroner concluded that “a lack of response by the out-of-hours GP service and a significant delay in attendance by the ambulance services may have influenced her survival”.
But the issues highlighted by coroners in relation to patient deaths are wider than ambulance delays. They include: lengthy elective surgery backlogs; high referral thresholds and long waiting times for children’s mental health services; a national shortage of neurologists; long waiting times for psychological therapies; a lack of mental health beds and unfilled mental health staff vacancies; and a shortage of cardiologists compounded by a shortage of theatre capacity and beds.
Katie Wilkins was a “bright, bubbly” 14-year-old from Warrington who was “always the life and soul of the party”, her mother Jeanette Whitfield told the Observer. She wanted to be a paramedic when she grew up.
But tragedy struck in the summer of 2020 – tragedy that was wholly avoidable. A painful abscess was mishandled by Katie’s local general hospital, delaying her eventual diagnosis with acute promyelocytic leukaemia (APML), a rare type of blood cancer.
After collapsing at home, she was referred to the Alder Hey hospital, where Whitfield says things went “from bad to worse”. APML has a high survival rate – the danger comes from severe bleeding, as APML impairs the blood’s ability to form clots.
The treatment Katie should have received was not administered correctly due to a shortage of the right specialist doctors. Those who did treat her made mistakes.
“They basically put more fluid in her than her body was able to handle,” said Whitfield.
On 29 July, Katie suffered a massive brain haemorrhage and died two days later.
A coroner ruled that neglect by the NHS contributed to her death. Her treatment should have been led by a paediatric haematologist, a specialist in blood disorders. But the inquest was told that Alder Hey had been unable to recruit sufficient haematologists.
The government’s response to the PFD said the number of haematology consultants working in English NHS hospitals had risen 56% since 2010. A statement from Alder Hey Children’s NHS foundation trust said these figures did not specifically relate to paediatric haematologists, which the trust said there was a national shortage of.
The trust added that it had “introduced new measures to ensure events like this will not happen again”.
A Department of Health and Social Care spokesperson said: “Each of these deaths is a tragedy, and our sympathies are with the families affected. We have invested record amounts into health and social care to ensure patients receive high quality care when and where they need it.”
A Welsh government spokesperson said: “The pandemic and recent unprecedented pressures have created challenges with patient flow in our health service, and this has had a massive impact on ambulances.
“The Welsh Ambulance Service has recruited 399 more ambulance staff over the past three years. A delivery plan is in place to improve response times and timeliness of patient handover, and to free up more time for staff to respond to calls.”
• The caption of the image of Katie Wilkins was amended on 27 February 2023 to clarify the cause of her death.
