Handover delays linked to number of Shropshire A&E deaths being higher than national average

Shrewsbury and Telford Hospitals Trust (SaTH) carried out a review of the situation at its two acute hospitals in December and found that there was "not a significant lack of medical or nursing care".

But the two hospitals have seen an increased rate of deaths in the third quarter of 2022-23.

Councillors have been told that in 2022/23 there were 404 deaths in emergency departments, of which 163 were referred to the coroner.

Hospital chiefs say work is ongoing to tackle the issues.

Dr John Jones, Medical Director at SaTH, said: “The review aimed to understand and address the recorded increase in deaths in our Emergency Departments, but it did not identify any overall failures or omissions in medical or nursing care impacting on patient outcomes.

“It did, however, confirm higher levels of mortality compared to the previous year, likely partly due to the 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 due to multiple factors and linked to significant and sustained demand across the system and the challenge in caring for complex patients with frailty and acute conditions.”

Dr Jones told the hospitals' board last month that "on the balance of probability" a number of issues are "contributing factors to a total increase in in-patient stay, harm events and mortality".

The issues he identified were ambulance off load delays, the emergency departments being over 200 per cent occupancy.

And the length of stay in A&E being "over 21 hours for an in-patient bed".

There are also delays in the handover of care within speciality teams.

Dr Jones added that it was "highly likely" that patients who would have died on the wards are now dying in the emergency department.

"However, overall, mortality for this quarter has significantly increased which may indicate a wider problem across the whole Integrated care System (ICS) which may require further exploration and is beyond the scope of this review."

He said that not only was the increased mortality at SaTH representative of a national picture, it was "higher than the national average."

"No firm conclusions have been identified during this review to explain this and it may require further exploration as part of a wider piece of work within the ICS to identify why mortality generally within the system has increased," he said.

"The findings within this review do appear to support the hypothesis that the increase in mortality within ED at SaTH correlates to data and wider published reports which suggest that a prolonged stay in ED leads to an increased mortality rate."

Councillors at a meeting of Shropshire's Health Overview and Scrutiny Committee on Monday were told on Monday that "increased deaths within the emergency department were likely to have been in part related to the increased length of stay within ED".

"This was likely to have had the greatest impact on older, frailer patients. This increase in deaths was representative of the national picture albeit the increase was greater.

"It is difficult to separate the effects of other delays occurring elsewhere in the system that are likely to coincide with times of excessive waits in ED and the review did not include patients who entered the hospital in a peri-arrest state or had sustained an out of hospital cardiac arrest."

Councillor Bernie Bentick, Lib Dem Spokesperson for Health said: “Shropshire’s emergency departments are truly shocking, with overcrowded waiting areas containing up to 30 patients which I have personally witnessed, who waited an average of 21 hours until admission in November 2023, despite a national publication showing higher death rates in crowded conditions and when admission waiting times were over five hours.

He added: “I call on Shropshire, Telford and Wrekin’s Integrated Care executives to visit Shrewsbury and Telford’s emergency departments on Friday and Saturday nights to see the extent of misery, unacceptable overcrowding and delays, to prioritise urgent care, reduce overcrowding and admission times to five hours or less and to put more experienced clinical professionals into the 111 phone service to reduce the number attending the hospital emergency services.”

Councillor Heather Kidd: “Rural dwellers have an even bigger stress on their health when faced with admission to our emergency departments – and that’s the huge waits they have for an ambulance before admission. This will add to the risks for those people as they wait in emergency centres. Releasing ambulances is therefore an important part of this.”

Councillors were told that health service system wide "improvement work is ongoing, including, but not limited to opening of two rehabilitation and recovery units (one on each hospital site) in January 2024 to provide additional capacity.

They have also introduced an ambulance delay escalation process to ensure additional actions in times of sustained pressure. There is also a protocol to increase capacity and relieve pressure within ED to alleviate overcrowding.

The hospitals trust has also taken a series of other steps including strengthening nursing leadership and working to ensure clinical colleagues have the necessary skills, training and processes in place to support our patients and to support quality, dignity and care for patients in these difficult circumstances.

The trust also wants to enable patients in hospital to be discharged as quickly as possible which will reduce waits for ambulances and those needing to be admitted. There are also changes Same Day Emergency Centre (SDEC) at PRH.

Ambulance Receiving Areas (ARAs) have been introduced at both hospitals. This helps to free up ambulances to respond to new emergency calls.

There are also new Rehabilitation and Recovery Units at both Princess Royal Hospital (PRH), Telford, and Royal Shrewsbury Hospital (RSH), run by Shropshire Community Health NHS Trust (Shropcom).

These units will provide general rehabilitation, often for people who are frail and elderly, or require specialist rehabilitation, for example people who have had a stroke or broken hips, who cannot be supported safely in their own homes, but do not need to remain in an acute hospital bed.