Madeline Constance Staples · Prevention of Future Deaths report

On the 11th of April 2018 I commenced an investigation into the death of Madeline Constance Staples (DOB 19.7.31 DOD 9.4.2018) The investigation concluded at the end of the inquest on 7th of February 2019. The conclusion of the inquest was one of an accidental death the Cause of Death being recorded as 1(a) Bronchopneumonia (b) Immobilisation due to Femoral and Tibial Fractures 2. Lung Cancer

On the 6th of April 2018 the Deceased (an 86 year old lady) had an unwitnessed fall in her care home. She had sustained long bone fractures of both legs as a result of the fall and the position in which she was lying prohibited her from receiving oral pain relief. An ambulance was called to her assistance at 22.11 hours however due to the absence of available resources (primarily due to lost ambulance hours awaiting discharge of patients at hospital) it was not possible to get assistance to her (and hence some pain relief) until 03.40 hours during which time she remained according to the attending paramedic, “crying out in pain which could be heard from the entrance of the care home despite her room being on the second floor”. A second ambulance was required to assist in her removal to hospital and again there was a delay in this being allocated due to an absence of available resources and she did not reach hospital until 05.23 around seven and a quarter hours after the first call for help. Despite treatment for her injuries her condition deteriorated and she died on the 9th of April 2019 at 23.20.

Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”.

In the intervening period from then until the present either I or my Assistant Coroners have issued at least a further twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAS T (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail.

As has been stated previously in my other reports, I recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable.