Albert James HAND · Prevention of Future Deaths report

On 12th November 2013 I commenced an Investigation into the death of Albert James HAND aged 79. The Investigation concluded at the end of the Inquest on 8th January 2014. The Conclusion of the Inquest was that the deceased had died as a result of an ‘accident’ - the medical cause of death being:

1(a) Subarachnoid Haemorrhage and Subdural Haemorrhage

Albert Hand suffered a fall at around 13.00 hours on 1st November 2013 at the Arndale Shopping Centre in Luton. A call was made to the Ambulance Service via 999 and a Paramedic attended at 13.32 hours who conducted an assessment and recorded a Glasgow Coma Scale (GCS) of 11. The Paramedic then requested a “Hot 2” transfer to hospital. The “Hot 2” ambulance arrived at 14.15 hours and left the scene at 14.37 hours, arriving at the Luton & Dunstable Hospital at 14.51 hours, almost an hour and a half following the original call. His GCS had then fallen to 7. The Clinical Manager for the Ambulance Service explained in his evidence that a patient could be waiting for up to three hours and “……the waits are getting longer”. Priority is given to diverting an ambulance to an incident where the person has suffered a respiratory or cardiac arrest, even in situations where the patient has suffered a head injury

(1) That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital

(2) That there are insufficient ambulance crews in the Luton and Bedfordshire area to meet the emergency needs of the community.

(3) That the Protocols in place for dealing with emergency calls are putting patients at risk and may result in future deaths.