Michael John VINCENT · Prevention of Future Deaths report

On 09 January 2023 I commenced an investigation into the death of Michael John VINCENT aged 79. The investigation concluded at the end of the inquest on 25 May 2023. The conclusion of the inquest was that:

Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED's because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the "down time" was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED's because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the "down time" was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.