Evidence of Risk to Life: Dorset Council’s referral of Dorset CCG’s Clinical Services Review: letter from Bournemouth Council

Defend Dorset NHS
 
The Rt Hon Matt Hancock MP
Secretary of State for Health and Social Care
39 Victoria Street
London SW1H 0EU
27th November 2018
 
Dear Secretary of State
 
Evidence of Risk to Life: Dorset Council’s referral of Dorset CCG’s Clinical Services Review: letter from Bournemouth Council
 
I write following Councillor d’Orton-Gibson’s letter to you of 22nd November, to give factual corrections regarding this matter of life and death.
 
The letter asserts that Dorset Health Scrutiny, and/or Defend Dorset NHS residents group, claims the changes will result in ‘the death of a resident’. Actually the figures are 396 emergency ambulance patients per year “at risk of potential harm” and that 183 of these patients are likely to die, if Trauma A&E Specialist Maternity services are no longer provided at Poole Hospital.
 
Dorset CCG calculated for the High Court, based on South West Ambulance Trust Report, that 132 residents over the 4 months of the Report, or 396 per year, would be “at potential risk of harm”. The CCG’s calculation is at Appendix 2 of the folder submitted, and attached for ease of reference.
 
Dorset CCG did not do the further work called for by the Ambulance Trust Report to establish the extent of the risk to these 396 patients. Nevertheless, many cases in the Ambulance Trust Report speak for themselves: a child post cardiac arrest, an unresponsive child who would face a 9 minute longer journey, a mum-to-be with ectopic pregnancy in extreme pain with internal bleeding and fatally low blood pressure facing a 19 minute longer journey.
 
A Dorset A&E Dr reviewed the cases in the Ambulance Trust Report and assessed that just under half were in imminent danger of dying, so that any longer journey was likely to prove fatal. This scales up to 183 likely fatalities per year – please see the table of likely fatalities and the calculation on the next page for ease of reference.
 
It is important to note here that 396 per year at potential harm and 183 per year likely to die is an underestimate, as the majority of Maternity & Paediatric emergencies do not arrive by Ambulance. A Freedom of Information Act request (attached) shows that Poole A&E saw 590 maternity emergencies last year, and that 456 of these (77%) did not arrive by ambulance. The majority of these Mums-to-be would have longer journeys, by car, to Bournemouth Hospital, which is in the far east of the County in an area of appalling traffic congestion. Dorset CCG’s own Consultants quote 30-45 minutes as maximum ‘safe’ travel time in Maternity Emergency.
 
Likely Dorset fatalities = 183 per year of those transported by Ambulance
if Trauma A&E & Specialist Maternity Services are lost at Poole
 
Taken from Ambulance Trust Report (Jan-Apr 17). See Cases below:
 
 
12 Adults from the 150 sample reviewed = 56 from the 696 Adults identified as at risk
 
56 Adults + 2 Maternity + 3 Children = 61 over 4 months, or 183 per year
Diagnosis
Maternity Paediatric
Or Adult
Details
Extra Journey Mins
Potential Harm
Overdose non opiate
Adult, 90
Overdose zopiclone and paracetamol
21
Yes – reducing Glasgow Coma Scale (GCS) and difficult airways management
Sepsis
Adult, 95
Chest sepsis – aspiration
21
Yes – red flag sepsis with shock, Glasgow Coma Scale 3, peri-arrest, 21 extra minutes without antibiotics
Haemorrhage
Adult, 91
Large rectal bleed
20
Possible large PR bleed, hypotensive and becoming shocked
Overdose – unspecified
Adult, 42
Mixed overdose
18
Possible – fluctuating Glasgow Coma Scale requiring airway intervention
Overdose – unspecified
Adult, 49
Unresponsive
17
Yes – airways management difficult
Trauma
Adult, 33
Knocked over by car? Knocked out.
14
Yes – agitated and dropping Glasgow Coma Scale
Diarrheoa and vomiting
Adult, 82
D&V sepsis
14
Yes – very hypotensive despite fluids
Sepsis
Adult, 83
Chest infection – likely sepsis
14
Yes – red flag sepsis with shock, Glasgow Coma Scale 6, peri-arrest, extra minutes without antibiotics
Stroke
Adult, 85
? Cardio-Vascualar Aneurysm
14
Yes – increased travel time with unconscious patient needing CT scan
Neurological
Adult, 84
Cerebro vascular event (CVE) haemorrhaging
9
Yes – Reduced Glasgow Coma Scale with possible CVE event
Stroke
Adult, 89
?Stroke or TIA – mild improvement
9
Yes – confirmed cerebro vascular event although still within window
Cardiac arrest
Adult, 76
Cardiac arrest after ambulance arrived
4
Possible, difficult to do CPR in moving ambulance for further minutes
Haemorrhage after birth
Maternity
No pulse improved en route
9
SWAST left blank
Ectopic pregnancy
Maternity
Extreme hypotension systolic bp 66mHg, pain score 10/10
19
SWAST left blank – bleeding into abdominal cavity causing fatally low blood pressure and extreme pain
Multiple Convulsion
Child
Child remained Glasgow Coma Scale 3
9
SWAST left blank – Glasgow Coma Scale 3 = unresponsive
Cardiac Arrest
Child
Post cardiac arrest
4
SWAST left blank
Medical
Child
Very sick child
4
SWAST left blank
To address other points in Mr d’Orton-Gibson’s letter:
 
The individual Health Scrutiny Committees in Dorset: Dorset County Council, Poole BC and Bournemouth BC, did not delegate the decision on whether to refer the Clinical Services Review to the Joint Health Scrutiny Committee which therefore has an advisory role. Dorset CCG failed to inform the Joint Committee on 12th December that the Ambulance Trust Report of August 2017 showed that 132 patients over 4 months were at potential risk of harm, and that the work to determine the extent of the risk had not been done.
 
To clarify the travel issues: our concern is about access to care in a medical, trauma or maternity emergency. Bournemouth Hospital is situated to the east of Bournemouth and in the far east of Dorset, in an area of appalling traffic congestion. The journey from Bournemouth to Poole Hospital is 8 miles, where the journey from Swanage to Bournemouth Hospital is 28 miles.
 
Regarding the number of Poole A&E patients who would be able to be treated at the proposed Poole Urgent Care Centre. Poole Annual Report shows that 68,000 attended A&E in 2017/18 and 55% of these (37,500 patients) were admitted, so would not be able to be treated at Poole Urgent Care Centre, notwithstanding that the CCG plan to close 407 (2/3) of Poole Hospital beds. The CCG’s own definition of what an Urgent Care Centre can treat is: minor injuries: sprains and strains, broken bones, wound infections, minor burns and scalds, minor injuries to the head and torso, insect and animal bites.
 
Claims that Dorset residents go out of County for care ignore the fact that they are stabilised at Poole first. That centralised services are not always the best clinical solution is demonstrated by South West Ambulance Trust, who, despite Bournemouth being the cardiac centre, took more cardiac arrests to Poole last year, because they deemed proximity more important to save life. The Keogh Report core research on stroke services related to London where time to reconfigured services was never more than 30 minutes. The Report itself stated it should not be used as a blueprint in rural areas, where longer travel time might outweigh any benefits.
 
To quote a Dorset A&E Dr working and living in this area for many years:
 
“If Poole A&E becomes an Urgent Care Centre, the CCG suggest that 19 minutes will be added onto the journey time for major treatment for Purbeck patients to get to at RBH, and it will be 8 minutes longer to Dorset County, which will not have Major Emergency Hospital, or Neo Natal high dependency or Intensive care services. Even 8 minutes is a long time for a critically ill patient and, quite simply, means the difference between life and death.
 
There are a range of conditions that cannot be treated in the ambulance where time to hospital treatment is critical, as the patient could die at any moment. It cannot, therefore, be argued with any honesty that longer journey time to access treatment is irrelevant in these cases. The Ambulance Trust Report corroborates this and identifies many patients whereby longer transfer time could have led to patient deaths or disability.
 
 
It may be true that those arriving at a better resourced centre are likely to do better, however this does not address the issue of those who die en route, or for whom treatment has come too late to avoid permanent disability.
 
Looking in more detail at the risk in several time critical conditions:
 
Strokes require an urgent CT scan to find out if it is appropriate to treat the patient with blood thinning drugs within the 4 hour time frame. An ambulance cannot treat, as they do not know what type of stroke it is. If relatives don’t recognise initially that the patient is having a stroke the ambulance call is already delayed. Once a patient arrives in hospital clinicians have 60 minutes for tests to be completed and analysed and treatment given: ‘door to needle time’.
 
In a heart attack, every minute delay to treatment will result in loss of heart muscle. In all heart attacks, the sooner the patient receives treatment, the better, as the heart muscle dies with each passing minutes. Hence the saying “minutes mean myocardium”.
 
Sepsis is a time critical condition where administration of antibiotics in a timely manner is crucial. Every hour delay in receiving antibiotics results in a 7.6% increase in the risk of mortality. Ambulance crews cannot give antibiotics for sepsis.
 
Respiratory emergencies need to be sorted out within 3 minutes to improve oxygenation and prevent hypoxic brain injury. In order to effectively ventilate a patient you need to get oxygen in and remove carbon dioxide. If a patient is unconscious or has a breathing problem they can’t ventilate and will require the skills of a paramedic, anaesthetist or A&E doctor. SWAST cannot always provide paramedics to these emergencies and ambulance crews would need to get the patient to the nearest A&E as quickly as possible to save life.
 
In cardiac arrest the patient may not be susceptible to defibrillation. Out of hospital survival rates for cardiac arrest are very poor – around 8.6%, while in-hospital rates about 20% depending on the many factors that influence outcome. The sooner these patients arrive in A&E the better for their chances of survival.
 
In major trauma, SWAST may decide the patient needs to go to the Major Trauma Centre at Southampton Hospital. However, the guidance recommends that the patient needs to arrive at the Trauma Centre within 45-60 minutes, which cannot be achieved from most of Dorset. In this incidence the patient would then need to be stabilised at Poole Trauma Unit within 45 minutes, before onward travel to Southampton Trauma Centre.
 
Unless measures are taken to consider how these time critical conditions would be affected by the Clinical Services Review plans, lives will be lost.”
 
Dorset Health Scrutiny’s referral is supported by Worth, Langton and Corfe Parish Councils, Swanage and Portland Town Councils, Purbeck District Council and Weymouth and Portland Borough Council. Also, 75,500 Dorset residents signed petitions, including 37,000 to save Poole A&E and Maternity.
 
There have been recent announcements of substantial funding for the NHS. The above service cuts relate to the situation prior to these announcements, and beg the question “What price Dorset Lives?”
 
Dorset residents implore you to consider this referral in full and request that the matter is passed to the Independent Reconfiguration Panel so that a full and independent assessment of the plans is carried out.
 
Yours sincerely
 
Debby Monkhouse
On behalf of Defend Dorset NHS Residents Group