John Trevor WINSWORTH · Prevention of Future Deaths report

On 24 February 2023 I commenced an investigation into the death of John Trevor WINSWORTH aged 92. The investigation concluded at the end of the inquest on 25 September 2023.

The medical cause of death was:
1a) Traumatic Intracranial Bleed
1b) Fall
1c)
2) Atrial Fibrillation (on Warfarin)

The conclusion of the inquest was:
Accident

Mr Winsworth was found on the floor at his home on 14 February 2023. Emergency services were called at 11.55 hours. An ambulance arrived at 09.30 on 15 February 2023 and Mr Winsworth was taken to Norfolk and Norwich University Hospital, arriving at 10.52 hours. He was admitted to Accident and Emergency Department at 14.42 hours. A CT scan showed a small bleed in the brain and Mr Winsworth’s Warfarin medication was stopped and he was given Vitamin K to promote clotting. Mr Winsworth was not referred to the Haematology Department in accordance with internal protocol, when it is probable medication to promote blood clotting within a shorter space of time would be prescribed. Mr Winsworth was assessed as fit to be discharged following examination and assessment. He was unable to get into a motor car and hospital transport was arranged. Mr Winsworth was returned to the ward. His condition suddenly deteriorated and he died on 21 February 2023 in hospital.

1. The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call, requiring a response within 2 hours. The ambulance arrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.
2. The ambulance arrived at the Norfolk and Norwich University Hospital at 10.52 hours and Mr Winsworth was not able to be admitted to Accident and Emergency Department until 14.42 hours; over 3 hours following admission, due to pressure on the hospital.
3. Considerable delays in attendance by EAST (East of England Ambulance Service Trust) to calls continues.