Harry Peter DUNN · Prevention of Future Deaths report

On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19. The investigation concluded at the end of the inquest on 13 June 2024. The conclusion of the inquest was:

Road Traffic Collision

The circumstances of the death are as follows: -

On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by ████████ an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Harry Dunn. The cause of the collision was that on exiting RAF Croughton ████████ inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton.

Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries.

He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.

(1) When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust (“EMAS”) or within the neighbouring South Central Ambulance Service Trust. The only available emergency medical resource was that run by the Air Ambulance Service Charity which was an advanced medical team based out of Coventry Airport, some c.30 miles away with an estimated arrival time of 57 minutes.

(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.

(3) Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because EMAS’s resources cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.

(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.