Joan Mary Corcoran · Prevention of Future Deaths report

On 19th December 2022 I commenced an investigation into the death of Joan Mary Corcoran. The investigation concluded on the 15th May 2023 and the conclusion was one of Narrative: Died from complications of heart failure whilst being transported to hospital for treatment contributed to by the complications of an accidental fall. The medical cause of death was 1a) Myocardial Infarction 1b) Heart Failure 1c) Hypertension 1d) Neck of femur fracture (operated on)

Joan Mary Corcoran had an accidental fall. She was operated on for a fracture to the neck of femur. Post-operatively she developed pneumonia. Subsequently the wound became infected, and a wound wash and debridement took place. She became increasingly frail. She was discharged home with support from the discharge to assess team. She felt unwell on 13th December 2022 and called for an ambulance with chest pains. Her initial call was dealt with as a category 5 call, and she contacted her GP. Her GP visited her and was concerned about her presentation. A further call to the ambulance service resulted in her being classified as a category 2 call. The blood tests taken indicated she was in severe heart failure and at a risk of a myocardial infarction. The ambulance arrived significantly outside the target Department of Health response times. The ambulance crew identified she needed urgent cardiac treatment and she was for transfer to hospital. Enroute to hospital she deteriorated further and died in the ambulance from complications of heart failure.

The inquest heard evidence that under the Department of Health’s Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.

The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time. A response within the target time would have meant that she would not have deteriorated and died in the ambulance. She would have been in a hospital with access to treatment available in such a setting.

The evidence before the inquest was that her case was not a one off and delays of this nature had been occurring throughout the day. The mean time for Category 2 response times that day was 1 hour and 22 minutes and the 90th percentile was just over 3 hours.

At 17.58 that day there were 142 emergencies waiting in Greater Manchester alone and 430 across the North West. The average response time at that point for Category 2 patients was 2 hours and 33 minutes. The inquest heard that the cause of these significant delays in patients receiving care in a timely manner was multifactorial and included the demand for ambulances across Greater Manchester and the North West and the long ambulance delays at A and E departments due to the demand on A and E services.