Lyn Mary BRIND · Prevention of Future Deaths report

On 07 June 2022 I commenced an investigation into the death of Lyn Mary BRIND aged 61.
The investigation concluded at the end of the inquest on 05 January 2023.

The medical cause of death was:
1a) Congestive Cardiac Failure
1b) Ischaemic and Hypertensive Heart Disease
1c) Coronary Artery Atherosclerosis and Morbid Obesity
2) Diabetes Mellitus

The conclusion of the inquest was:
Mrs Brind died from cardiac failure. Her condition was not diagnosed nor treated in a timely fashion.

On 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the Ambulance Navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind's condition continued to deteriorate and she died at 17.52 hours.

1) Evidence was heard that there was a delay in Mrs Brind being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital
2) As delays are a reoccurring problem, checks are made by paramedics and Hospital clinicians on patients while they wait in ambulances for transfer into the hospital to assist in prioritising the need for transfer.
3) In the case of Mrs Brind, physiological observations were not undertaken regularly in accordance with East of England Ambulance Service Trust (EEAST) Guidance and when they were taken, her high NEWS2 score was not escalated to the Hospital Ambulance Navigator who assesses priority for beds in the hospital.
4) Further Mrs Brind was not assessed by a Senior Doctor from the Hospital within an hour, in accordance with Hospital protocol
5) I am satisfied that steps have been taken by both EEAST and the Hospital in respect of these matters and do not make a report in respect of either of these matters
6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays.
7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community.
8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department.
7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community