Ambulance death underlines A&E capacity issues

As widely-reported in the media – Welsh and UK – on January 16th, 58-year-old Michael Bowen from Ogmore Vale, died at Bridgend’s Princess of Wales Hospital after waiting in an ambulance outside the A&E department for four hours.

This is the latest in a string of concerns about excess deaths, which have already prompted a high-level review and procedural changes at the hospital.

The latest reports in the Glamorgan Gazette say there’ve been serious problems at the hospital throughout January. Union reps representing paramedics say waits to be discharged from ambulances have ranged from 30 minutes to 5 hours – regardless of how serious the emergency. It’s also been reported as many as 10 ambulances have been waiting outside A&E at any one time.

It comes as a recent BBC investigation showed ambulances in Wales faced some of the longest waits to transfer patients to A&E departments in the UK, though the average in Wales is said to be around 20 minutes.

In Abertawe Bro Morgannwg (ABM) Local Health Board’s official statement, they say that after being seen by a doctor (in the back of the ambulance), Mr Bowen suddenly became very ill in the A&E department around two hours after being admitted, subsequently dying despite resuscitation attempts. ABM say the A&E department was “extremely busy at the time….and there were delays admitting patients as a result.”

ABM have launched an “urgent inquiry”, while they also clarify that despite media reports, South Wales Police are not “carrying out an investigation” but gathering evidence for the coroner – which is standard procedure. The coroner’s inquest has subsequently opened and been adjourned until May.

It’ll be for the coroner to determine what caused Mr Bowen’s death, and nobody – apart from medics and anyone else with him at the time – will have any idea what state he was in when he was at hospital.

However, I suspect most people in the Bridgend area will be asking whether Mr Bowen would’ve stood a better chance of survival if admitted sooner?

A patient dying after waiting in the back of an ambulance for several hours, metres away from advanced life-saving equipment, is an absolute disgrace that can’t be sugar-coated by anyone. The Welsh NHS is a first world service, but that’s a third world death.

It’s nobody’s “fault”. On the surface of it, the Ambulance Service are, at least, blameless this time.

Putting the tragic loss of life aside, what this incident does underline are long-standing issues plaguing the NHS, not just in Bridgend but across Wales.

Late morning-early afternoon is the busiest time for A&E departments. On top of that, you have to add people going to A&E when they shouldn’t and the impact of winter bugs like norovirus – people had already been warned to stay way from Bridgend’s A&E unless urgent.

I’m sure the thought of people sharting en masse is very amusing (if you have a sick sense of humour like myself), but it can become very serious, very quickly for the elderly and infirm (of which there are proportionally more in Wales) – justifying hospitalisation.

Winter illnesses are highly infectious, spreading around hospitals, shutting wards and blocking beds very quickly. Ward 10 at the Princess of Wales Hospital is already closed to visitors due to “diarrhoea and vomiting”.

In dealing with it, hospitals are caught in a catch-22.

They can firstly send people home, or encourage people not to come in. As a result, the vulnerable suffering from winter illnesses might not get the right treatment and become gravely ill, ending up referred to A&E departments either by their GPs or because there’s no other alternative.

Or, hospitals can admit the most serious cases, filling beds (and bed pans) and risk infections spreading, albeit with isolation protocols in place.

While some members of the public choose to ignore advice about staying away, hospitals have no choice but to admit people.

The Welsh NHS and Welsh Government need to find a way to make treatment at home practical, because it’s typical for people to turn up at A&E no matter what and expect treatment, when a day or two in bed or a trip to a pharmacy is often a better option. As a result, people are stuck in ambulances outside A&Es.

Another long-standing reason for admission delays are, of course, staffing and treatment capacity issues.

Firstly, if a patient was waiting in an ambulance for four hours, that ambulance was also out of action for four hours – one less ambulance to respond to 999 calls in the Bridgend area, increasing ambulance response times.

The proposed reorganisation of hospitals across Wales aim to deal with the staffing problem by concentrating specialist staff on fewer sites. One major part of the South Wales Programme, which hasn’t been sufficiently addressed in the consultations as far as I can tell, is that of capacity – the number of beds and treatment areas available at the proposed centralised A&Es.

Those centralised A&Es will serve a larger catchment area, seeing more patients as a result. Since Neath Port Talbot Hospital’s A&E department was downgraded to a minor injuries unit in 2012, the Princess of Wales has provided A&E cover for the Port Talbot area . If Option 3 of the South Wales Programme is chosen, then the Princess of Wales could see some emergency patients from the Rhondda and Ely Valley on top of that.

Emergency beds, high dependency units and clinical decision units come with hefty price tags. However, the reorganisation plans – as far as I can tell – will mean a similar number of treatment places, in fewer A&Es, just with proportionally more doctors available to see anyone who comes through the door.

Does that sound “safe and sustainable”? Do you see how ambulance queues could get worse as a result?

The image conjured – post reorganisation – is of crowded emergency departments, and doctors who can’t do anything until beds clear and ambulances unload….oh.

Judging by answers given in the National Assembly this week, the Welsh Government and health boards are undertaking a review into how A&Es work in order to “improve patient flow”.That’s welcome and long overdue.

Having said that, those A&E capacity issues should’ve been sorted before reorganisation plans, not as those plans are being finalised. If they were, the plans might’ve been more convincing, instead of leaving unanswered questions and doubts hidden beneath a technocratic undergrowth.

Local Health Boards and politicians can squeeze as many doctors they want into as few hospitals as they want, but….

Give a doctor a patient in an ambulance that arrives on time, give that patient a bed, and give both access to equipment, treatments and nurses, and the doctor is then practicing emergency medicine.

Take away the bed, prompt ambulance transfers, equipment, treatments and nurses, and a doctor’s nothing but a first-aider who happens to have a medical degree.