Coroners' death reports reveal rise in NHS warnings.

A total of 109 warnings to health bodies and the government highlighting long NHS waits, staff shortages or a lack of NHS resources were sent by coroners in England and Wales in 2023, the BBC has found.

Prevention of future death reports (PFDs) are sent when a coroner thinks action is needed to protect lives. The number of cases identified, linked to NHS pressures, was the highest in the past six years.

The BBC researched hundreds of PFD reports written after inquests to find cases linked to long NHS waits or pressure on the health service.

The 109 identified in 2023 compared with 58 in 2019, and 49 in 2018, before the pandemic. The BBC also found 62 cases in 2022, 45 cases in 2021, and 37 in 2020, when it was more likely Covid may have affected the number of inquests held and reports written.

About 35,000 inquests are held in England and Wales each year. In a fraction of those, about 450, the coroner writes a PFD, or Regulation 28, report.

The BBC analysed 2,600 PFDs sent between 2018 and 2023. The proportion of the total number of PFD reports that referenced NHS resources rose to one in five in 2023, from one in nine in the two years before Covid. 

Of the 540 reports written  in 2023, 109 highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners. Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services. Sixteen of the 109 PFDs linked to NHS pressure in 2023 were written by coroners in Wales.

School boy William Gray,10, died after a life-threatening asthma attack. In October 2020, he was struggling to breathe during the night. His mother gave him CPR and he was rushed to Southend Hospital by ambulance, only to be discharged four hours later.

In the following months, his family tried and failed to get the specialist help they needed. Some changes were made to William's inhaler but, after a consultant appointment, he was "lost to follow-up" at the hospital, his inquest heard. His GP did not prescribe continuing preventative medication to control his condition.

At the time of his admission, there was only one nurse in the children's asthma and allergy service in south-east Essex, increasing to two in November 2020. Staff had a caseload of 2,000 children and demand was growing, with referrals up 75% between 2018 and 2023.

On 29 May 2021, William had another severe asthma attack. This time doctors could not save him, and he died in hospital.

After William's inquest in December 2023, the coroner wrote a strongly worded PFD report to health secretary, Victoria Atkins, and the NHS bodies responsible for his care saying that the children's asthma service "remains under-resourced." She said that William's death was "avoidable", and better treatment "would and should" have saved his life.

In response, Essex Partnership University NHS Trust said it had recruited three more asthma nurses through a pilot scheme, although it had requested funding for eight. Mid and South Essex NHS Trust, which runs Southend Hospital, also said it had introduced "numerous changes" to improve patient care. 

Among the 26 cases involving mental health issues or suicide was that of Shaun Parks, 52, who was driven to Doncaster Hospital in December 2022 with chest pains. He arrived at midnight and waited in the A&E department for more than an hour before being seen.

After a nurse said that Shaun Parks was having a heart attack, he was taken to the resuscitation area to be stabilised.

He was then told he needed to be moved to a specialist unit in Sheffield, but his inquest heard high demand and staff shortages meant the ambulance, which should have arrived in 18 minutes, took more than three hours to pick him up from Doncaster. Shaun died in hospital later that morning. 

In a PFD sent to the Department of Health in December 2023, the coroner raised concerns about the "significant delay" ambulances were facing offloading patients, and noted that Mr Parks had "deteriorated during his time at Doncaster Royal Infirmary."

After his inquest, NHS West Yorkshire Integrated Care Board, which commissions ambulance services in the region, said it had been investing in more staff and vehicles, though it accepted there were "ongoing challenges" with response times.

President of the Royal College of Emergency Medicine, Dr Adrian Boyle, said:" Reading the reports is heart breaking, and our thoughts are with the families and loved ones of all those who died.

"The link between the issues highlighted and the pressures currently being experienced by our urgent and emergency care system is stark. This is also supported by scientific evidence which shows the single leading theme is delay."

NHS trusts, government departments and other organisations have a mandatory duty to respond to PFD reports, but any changes recommended by the coroner are not legally enforceable. 

In a statement, the Department of Health and Social Care in England said it learnt from every PFD report. A spokesman said: "Our £1bn urgent and emergency care plan sets a clear vision for how we are working to cut waiting times alongside a £2.4bn plan to train, retain and reform the NHS workforce.” 

"Despite ongoing pressures from record demand and high bed occupancy, the NHS continues to focus on improving patient flow, ensuring patients are seen by the most appropriate services and minimising delays."