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Investigation and inquest
On 11th January 2023 I commenced an investigation into the death of Bernhard John Marek .The investigation concluded on the 31st May 2023 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Hospital Associated Pneumonia; 1b) Fractured Neck of Femur (operated); II) Squamous Cell Carcinoma Lung, Acute Kidney Injury
Circumstances of the death
Bernhard John Marek (date of birth 2nd October 1946) had an accidental fall whilst walking from his car to a coffee shop. He could not weight bear following the fall. An ambulance was called. There was a 16 hour wait for an ambulance at that point. He was outside in the street in December. He was moved with assistance from members of the public to his car and driven home where an ambulance was again called for. He remained in his car whilst waiting for an ambulance as he could not mobilise from the car. The ambulance took him to Stepping Hill Hospital. He was diagnosed with a fracture to the neck of femur and admitted after a 9 hour wait in the emergency department. He was operated on. Post operatively his kidney function deteriorated further from his baseline. He required oxygen and his early warning score fluctuated. On 6th January 2023 he deteriorated rapidly having developed pneumonia. He died in Stepping Hill Hospital on 6th January 2023.
Coroner’s concerns
The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service and that such delays were not unusual throughout December due to demand and resources. As a consequence frail elderly patients such as Mr Marek with hip fractures were regularly waiting significant periods of time for the ambulance service.
The resource issues faced by the ambulance service were exacerbated by long delays faced by ambulances to offload patients at Emergency Departments.
Information checked against the published report and official responses