Pin
Get email alerts
Request correction
Investigation and inquest
On 20 December 2022 I commenced an investigation into the death of Dennis John William KING aged 84. The investigation concluded at the end of the inquest on 29 November 2023.
The inquest was heard without a Jury.
I returned the following narrative conclusion:
Dennis John William KING died as a result of recognised complications following necessary, life-saving emergency treatment for a myocardial infarction.
The medical cause of death was confirmed as:
1a Multi Organ Failure
1b Post myocardial infarction left ventricular free wall rupture (operated on)
Circumstances of the death
On the evening of 9th December 2022, Dennis John William KING suffered sudden chest pain which extended down his arm. At 22.51PM Mr. KING's wife called 999 and spoke with an ambulance service call handler. Following triage of the call, the response to Mr. KING's call was graded as a Category 3 (a potentially urgent condition which is not life threatening with a target response of 120 minutes). This call was subsequently re-graded following review in the call centre at 23.18PM to a Category 2 (a potentially serious condition requiring rapid assessment, urgent on scene intervention or transport to hospital, with a response within 40 minutes and a target of 18 minutes).
At 23.53PM Mrs. KING called again to enquire after the estimated time of arrival for the ambulance and was advised that due to high demand in the West Suffolk area that evening, the waiting time for an ambulance could be as long as six hours. On receiving this information Mr. and Mrs. KING decided to make their own way to the West Suffolk Hospital arriving there at 00.58AM on the 10th December 2022. The ambulance service were advised and the response stood down.
Within 40 minutes of arrival Mr. KING had been diagnosed as suffering an ST segment elevation myocardial infarction (STEMI) and arrangements made for him to be received as a patient at the regional specialist centre at the Royal Papworth Hospital for an urgent
angioplasty procedure to be performed. The time was 01.44AM, 10th December 2022. Mr. KING's condition at this point was stabilised and he was being closely monitored in a resuscitation room. Treating clinicians assessed his condition as necessitating an urgent transfer to the Royal Papworth and for the angioplasty procedure to be conducted forthwith.
The ambulance call centre was contacted by the hospital emergency department at 01.37AM with a request for an urgent transfer to the Royal Papworth. Emergency department staff were advised that there would be a 5 hour delay for an ambulance to attend. The call from the hospital emergency department to the ambulance service was graded by the ambulance call handler as a category 2 response. When the response timing was challenged the emergency department matron was advised that the hospital was a place of safety. The ambulance call handler assessment did not seem to take into account the clinical assessment of accident and emergency department staff who, in consultation with the regional cardiac intervention hospital, had determined Mr. KING's further treatment at the regional cardiac centre was a matter of urgency.
An ambulance subsequently arrived at West Suffolk Hospital Accident and Emergency Department at 04.36AM and then transferred Mr. KING to the Royal Papworth Hospital, arriving at 05.56AM on the 10th December 2022. Mr. KING underwent treatment for what was identified as an occluded left anterior descending artery. The procedure was completed without incident and Mr. KING was placed on a cardiac ward.
About 1 hour after the procedure, Mr. KING's condition deteriorated and he suffered a left ventricular wall rupture, a recognised complication of either the myocardial infarction he had suffered or the surgical procedure to correct the occluded artery, or both. Mr. KING received emergency surgery to repair the rupture by way of a patch which was successful. However, Mr. KING's condition deteriorated and he died on the 13th December 2022.
Coroner’s concerns
a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
Information checked against the published report and official responses