Ambulance handover delays and 21-hour waits for a bed in accident and emergency contributed to an increase in harm and mortality at a struggling trust, a review has found.

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More patients ‘now dying in A&E’ finds trust review

By Emily Townsend 5 January 2024​

• Shrewsbury and Telford A&E deaths investigated
• Emergency care waits “contributing factors” to increased mortality
• Meanwhile, Royal Cornwall announces it will review its ED deaths

Ambulance handover delays and 21-hour waits for a bed in accident and emergency contributed to an increase in harm and mortality at a struggling trust, a review has found.

Shrewsbury and Telford Hospitals Trust investigated a cluster of deaths at its two emergency departments last winter and published a report last month.

The review identified 140 emergency care deaths at SATH between October and December 2022, up from 75 the previous year. It also found that this rise was higher than the national average.

One chart included in the report suggests the percentage of unplanned attendances who died in ED nationally in December 2022 was 0.2 per cent, while SATH’s figure was significantly higher at 0.6 per cent.

The peer (yellow) line on this chart represents the national average 

 

Excluding patients who arrived at ED in a peri-arrest condition, 83 patients were identified as having died in A&E between October and December 2022, and SATH chiefs decided to analyse care provided to 33 people. 

One key finding was that capacity and flow issues across the trust impacted harm and mortality.

Reviewers found “on the balance of probability, the ambulance offload delays, the ED running in the ‘majors’ area of the department at 200 per cent occupancy, length of stay in the ED over 21 hours for an inpatient bed, and handover of care within the specialty teams, are contributing factors to a total increase in inpatient stay, harm events and mortality”.

The review also said a hypothesis that the increase in ED mortality was “as a result of capacity and flow issues across the trust, resulting in patients who would have died previously on the wards, now dying in the ED”, was “highly likely” to be accurate.

However, it also said overall mortality significantly increased, which reviewers suggested “may indicate a wider problem across the whole integrated care system”.

SATH’s medical director John Jones said the review did not find the increased mortality rate was linked to a significant lack of medical or nursing care. However, 13 people who died had sepsis, and half of them experienced care failures around recognition, escalation, monitoring, and communication. 

 

Dr Jones added: “[The review] did, however, confirm higher levels of mortality compared to the previous year, likely partly due to higher mortality seen nationally, and partly due to the increased period of time that patients spend in emergency departments, rather than in inpatient beds.

“This has been shown in research studies to be associated with higher mortality. The reason for this is likely to be… linked to significant and sustained demand across the system, and the challenge in caring for complex patients with frailty and acute conditions.” 

One national study referenced in the review suggested mortality rates increased in patients waiting more than five hours for a bed in ED. For those delayed by eight to 12 hours, researchers identified an additional death for every 72 patients.

Reviewers said the mean time for admission to an inpatient bed in November 2023 at SATH was 21 hours.

SATH has significant and documented performance problems and was one of five trusts recently called in by health secretary Victoria Atkins to discuss long ambulance handover delays and emergency care waiting times.

Another troubled trust announces A&E harm review

Another hospital trust under scrutiny for excessive ambulance handover delays has launched a review into potential harm to patients waiting in A&E.

The review at Royal Cornwall Hospitals Trust is being carried out by the trust together with Cornwall Integrated Care Board, according to the trust’s November board papers. 

Although the review will also look at deaths associated with specialty waiting lists, an RCHT spokeswoman said they are looking “most specifically at potential harms associated with delays in our emergency department”.

The spokeswoman added the review’s outcome would be “openly reported” through board meetings.

Similar to SATH, RCHT has been grappling with long ambulance handover delays  and was also among the providers called to the meeting with Ms Atkins.

In his CEO update  to the board this month, Steve Williamson said Ms Atkins had required the trusts to “rapidly take further actions” to reduce ambulance handover delays and to review “all further extraordinary options”.

He said the trust had one of the highest proportions of ambulance arrivals at its ED of any major hospitals in the South West, and that the “vast majority” of ED attendees are more likely to need admission because the population is “particularly good” at using Cornwall’s 10 minor injury units.

The trust’s bed occupancy is currently 98 per cent, with more than 120 patients (around a sixth) stuck in hospital awaiting discharge.