Andrew Collins · Prevention of Future Deaths report

On the 25th June 2018 I commenced an investigation into the death of Andrew Collins. The investigation concluded at the end of an inquest on the 26th September 2018. The conclusion from the inquest was that of “Natural Causes”.

On the 6th June 2018 the deceased became acutely unwell at his home address with a sudden onset of severe headache. He deteriorated rapidly and became unconscious. On admission to the University Hospital of Wales in Cardiff scanning revealed a subdural haematoma. He underwent emergency neurosurgery to evacuate the haematoma, never recovered and passed away on the 16th June. He was on life time anticoagulation for atrial fibrillation. He was anticoagulated with warfarin. It was alleged that he was subject to an assault in which he was struck to the head with a bar on or around the 27th May. The evidence both from clinician and pathologist failed to make a link between the assault and the bleed. The evidence indicated that the bleed was far more recent and likely to have commenced seventy two hours before his admission to hospital on the 6th June.

[BRIEF SUMMARY OF MATTERS OF CONCERN]

(1) There was a delay of some 3 hours in sending an ambulance to Mr Collins when it was clear that his clinical picture was rapidly deteriorating.

The first 999 call was received at 16:10 on the 6th June and correctly categorised but no vehicle was available to be dispatched to assist him. A further 999 call was made by his partner at 18:09 and again at 18:55 at which point he was described as “just about breathing and just about conscious”. An ambulance became available and was on scene at 19:10. He was conveyed to the University Hospital of Wales at 20:08 and handed over to hospital staff at 20:26.

Whilst the evidence suggested the calls to the ambulance service were correctly categorised as having urgent clinical priority a clear lack of resources meant that there was a significant delay in attending to a critically unwell and deteriorating patient which, in my opinion must create a risk that further deaths may occur.