Mrs Withers · Prevention of Future Deaths report

The investigation commenced on the 19th February 2015. A post mortem was conducted by ████████ Consultant Histopathologist. Further evidence was obtained in relation to the deceased’s background and medical treatment by paramedics and hospital staff. East Midlands Ambulance Service provided a “Description and Consequences report”.

The resumed inquest took place on the 18th June 2015.

The GP’s evidence was read under rule 23. Live evidence was taken from:
1. ████████ Orthopaedic Registrar at Kettering General Hospital
2. ████████ Assistant Director of the Operations Centre for EMAS
3. ████████ (deceased’s son)
4. ████████ Consultant Histopathologist

The finding at inquest was that on 30th January 2015 at 22.10 hours, the deceased had a fall at her home. An ambulance conveyed her to Kettering General Hospital where death was confirmed at 02.26 hours on 31st January 2015.

A narrative conclusion was delivered in the following term
“Mrs Withers’ death was accidental however her death was contributed to by neglect. The 2 hour 50 minute delay between the 999 call being placed and the paramedic arriving probably did on the balance of probabilities contribute to Mrs Withers’ death”

Mrs Withers was 77 years of age. She suffered significant medical problems and required constant home oxygen. Mrs Withers was attended at home by carers and the Rocket team.
Mrs Withers suffered a fall sustaining injury and was immobile and unable to make telephone calls. A lifeline was activated. The paramedics arrived after a delay of 2 hours and 50 minutes.
The Pathologist’s findings were that the deceased suffered a fracture of the left pubic ramus as a result of a mechanical fall. This led to a significant blood loss into the soft tissues and the consequence of this significant haemorrhage resulted in cardiac arrest.

1) The policy in relation to obtaining a patient’s medical history during the first 999 call, reporting an incident.
2) The policy in relation to calling back a life line/third party where the patient is unable to receive calls.
3) The policy/procedure in relation to saving essential patient medical history in the ambulance service electronic data systems.
4) The policy in relation to staff abstraction tolerance and levels.
5) The policy and protocol in relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover of patient to hospital.)