Jean WALKER · Prevention of Future Deaths report

On 19 December 2023 I commenced an investigation into the death of Jean WALKER. The investigation concluded at the end of the inquest on 20 March 2024. The conclusion of the inquest was that;

Mrs Jean Walker died on 4 November 2022 having collapsed struggling to breathe at her home address ████████ Sheffield. An ambulance was called but delays to its arrival resulted in a missed opportunity to give medical assistance. It cannot be said that if she had received earlier intervention that her death would have been prevented.

1a Pulmonary Emboli

1b Deep vein thrombosis

1c

II

On 4 November 2022 Mrs Walker called her daughter as she was feeling unwell. Her daughter attended her at her home address and at 0348 called 999 as she was struggling to breathe. The call was correctly coded as a Category 2 (expected response time of 40 minutes) and Mrs Walker's daughter was told an ambulance would be with her within 40 minutes.

An ambulance was dispatched at 0526, arriving at 0542. At some point between the 999 call at 0348 and the ambulance arrival at 0542 Mrs Walker died. She was pronounced dead at 0551 by the attending paramedic.

(1) The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.

(2) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.