Coroners slam Cornwall's 'burnt-out' health system in damning report into 'avoidable' deaths

Two coroners have condemned health services in Cornwall in damning reports into deaths at the Royal Cornwall Hospital.

The Senior Coroner for the county highlighted concerns with long ambulance delays, staff-burn out, bed blocking and recruitment issues.

In a scathing Prevention of Future Deaths report he called on the government to take action to prevent future patients in the area from 'dying avoidable deaths'.

Senior Coroner Andrew Cox and Assistant Coroner Guy Davies highlighted their concerns based on the cases of four patients.

The findings were sent to the Royal Cornwall Hospitals Trust (RCHT), the South Western Ambulance Service Trust (SWAST) and the Secretary of State for Health and Social Care.

John Seagrove, Pauline Humphries, Patricia Steggles and Kenneth Heard all died at the Royal Cornwall Hospital in Truro in the past two years.

All four had called 999 for an ambulance but had to wait between 16 and 24 hours to be admitted to the emergency department.

Mr Cox warned that all four deaths feature inadequate delays in ambulance response times and handover times from the ambulance crews to hospital staff.

He highlighted that the deaths were not isolated cases, but instead an "illustration of the sorts of cases the area has dealt with regularly."

The report said: "It was acknowledged in the evidence that matters had improved over the summer (in 2021).

"What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15 to 20 ambulances waiting outside the emergency department on occasions over the last three weeks.

"I have spoken to the medical director at RCHT and he has confirmed that is the current position. This concern is compounded by the recognition that we are yet to experience the additional pressures that winter will bring.

"During the course of these inquests, the evidence has revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken."

He added: "The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix.

"They are too big for either the hospital trust or the 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.

"It is not for me as coroner to make recommendations on how you do that and so I leave that to you."

In his own report, Coroner Davies added: "The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.

"It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision.

"This means that wards are accommodating patients who would otherwise be discharged.

"The hospital wards being full beyond capacity means that emergency departments are unable to move patients out of emergency beds into the wards.

"This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays."

In November 2022, it was revealed that ambulance response times in Cornwall were amongst the worst in the UK.

In October this year, the Royal Cornwall Hospital was placed on the highest alert level as it struggled to cope with pressures.

In response to the reports, a spokesperson for Cornwall and Isles of Scilly Integrated Care System, said: “Our sincere condolences go to the families of the patients whose deaths are referenced in the coroner’s report.

“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 the hospital.

“We continue to work hard together to improve ambulance response times and delays at our emergency department but acknowledge we still have more to do.

“Over the winter months, the focus for our health and care system is on providing as much care as possible in people’s own homes or in the community, so that only those most acutely unwell or injured need to come to our main hospitals.

"The expansion of virtual wards, where people can be remotely monitored at home, more community hubs and additional resources for care and support packages will all play an important role.

“Our population can help us too by considering carefully which services are most appropriate for their needs and our ‘Where is best’ campaign is designed to help them in making those choices, including self-care, pharmacies, and minor injury units.”

The Department for Health and Social Care has been contacted for comment. It has until January 20 to respond to the reports.