Coroner criticises health board for ‘normalising’ treating patients in corridors
It comes after a 16-year-old boy died after having to wait nine hours for an ambulance.
A coroner has criticised a health board for “normalising” treating emergency department patients in corridors and slowing down ambulance handovers.
The “unsafe” practice also compromises patients’ hygiene, nutrition and ability to sleep, the coroner said.
Coroner David Regan issued Cwm Taf Morgannwg University Health Board in South Wales with a prevention of future deaths report after a 16-year-old boy died after having to wait nine hours for an ambulance.
Jackson Yeow was unable to make it to a GP appointment on April 4 2022, after his gastritis symptoms worsened.
His mother dialled 999, but despite several follow-up calls, an ambulance did not arrive until after he had became unconscious approximately nine and a half hours later.
The ambulance service categorised the call as life-threatening and needing an urgent response, the assistant coroner for the South Wales Central area said.
He was eventually taken to the University Hospital of Wales in Cardiff, where he was diagnosed with diabetic ketoacidosis, pancreatitis, cerebral oedema, renal compromise and severe acidosis.
Despite “intensive treatment”, his condition deteriorated and he died on April 9 2022.
During his inquest, the ambulance service said its ability to respond to the call had been “substantially impaired” because a significant number of its ambulance crews were delayed at hospitals waiting to hand over patients.
Although the Cwm Taf Health Board did not provide direct care to Jackson when he was taken ill, his inquest was told about the effect of delays in ambulance handovers at the board’s Princess of Wales Hospital in Bridgend.
Outlining his concerns, Mr Regan said care for patients in the emergency department is “frequently” provided in the corridor and other non-clinical spaces.
Treating patients in corridors can “slow the process of ambulance handovers”, he said.
It also impedes “efficient clinical assessment”, causing clinicians to take longer performing tasks, and the “ability of staff to recognise a patient’s deteriorating condition”, he added.
“Care in corridors and other non clinical spaces has been normalised, which in the opinion of the consultant who gave evidence is unsafe.
“When conducted routinely, care in corridors and other non-clinical spaces reduces the capacity of the emergency department.
“In my opinion, action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action,” he told the health board.
The chief executive will have 56 days to respond to the report.
Copies were also sent to the Welsh Government, the chief executive of the Welsh Ambulance Services NHS Trust and the chief executive of the Cardiff and Vale University Health Board.
In December, the Welsh Ambulance Service declared a critical incident because of significantly increased demand and extensive handover delays.
The service, which covers three million-plus people across Wales, said more than 340 calls were waiting to be answered at the time.
