Josh Andrew Smith · Prevention of Future Deaths report

On 6 January 2023 an inquest was opened into the death of Josh Andrew Smith, aged 30 years.

The inquest concluded on 4 July 2024 by way of a narrative conclusion, worded as follows: On a background of longstanding medical complications arising out of quadriplegia sustained in a historic road traffic incident, Josh Andrew Smith died of hypoxic brain injury secondary to an out of hospital cardiac arrest which was caused by underlying natural disease processes.

Mr Smith had a long-standing history of medical complications, consequent to quadriplegia which arose following injuries he sustained in a road traffic incident in 2009.

On 16 December 2022, Mr Smith spoke with a General Practitioner over the telephone and was prescribed antibiotics for a chest infection.

On 19 December 2022 at approximately 05:49 hours, an ambulance was called for Mr Smith as he had been found unresponsive and was not breathing. The 999 call was placed within a queue and was answered by the ambulance service at 06:05 hours. The ambulance service triaged this call and a Category 1 response was achieved. An ambulance arrived with Mr Smith at 06:21 hours,

Mr Smith was conveyed by ambulance to Hull Royal Infirmary where it was identified that he had suffered a hypoxic brain injury. CT scans also demonstrated evidence of bronchopneumonia and Mr Smith ah tested positive for influenza A.

Despite maximal treatment, Mr Smith’s condition did not improve and he was placed on palliative care. Mr Smith died on the 22 December 2022.

I heard evidenced that whilst the Yorkshire Ambulance Service have taken a number of steps within their powers to try to reduce the delays experienced by patients waiting for an ambulance within the community, that those delays continue.

Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr Smith’s death, still remain outside of the target response standards (both on average and at the 90ᵗʰ centile).

The evidence heard was that the national target for hospital handover by the ambulance service, of 15 minutes, is still not being achieved. Evidence suggested that whilst there has and continues to be efforts made by the ambulance service and acute hospitals to increase the speed at which ambulances handover their patients, that delays in this process continue to impact upon the speed of the ambulance response to patients waiting within the community.