JOHN SCOTT MURPHY · Prevention of Future Deaths report

On 12th July 2021 I commenced an investigation into the death of JOHN SCOTT MURPHY then aged 46 years. The investigation concluded at the end of the inquest on 21st April 2022. The conclusion of the inquest was natural causes.

The medical cause of death being

1a Covid-19 Pneumonitis

II Hypertensive Heart disease.

John Murphy tested positive for Covid-19 infection in the week before he died. His family reported that he seemed to be improving although he was extremely fatigued. He lived alone and was alone in his home when he started to deteriorate in the early hours of Sunday 11th July 2021. At 03:20 he called the North West Ambulance Service and he reported that he was breathless too fast. The Service were dealing with extremely high demand at that time and had escalated its Patient Safety Plan response to Level 4, Tier 5. Mr Murphy was categorised as category 2 patient needing emergency care. An ambulance arrived at his property at 05:21 and by that time he had passed away. A post-mortem examination confirmed that he had undiagnosed hypertensive heart disease which can be a risk factor for a poorer outcome with COVID 19.

A number of measures have been undertaken by the North West Ambulance to address emergency response times including:
• Utilising the Voluntary Aid Service and private ambulance support,
• Ongoing recruitment, although it is acknowledged that this takes time,
• The introduction of a Clinical assessment of category 3 cases rather than automatic ambulance allocation,
• Movement to NHS pathway tool from MPDS which changes the way Category 3 and 4 calls are managed again to reduce ambulance allocation.

Live waiting times in Greater Manchester during the Inquest hearing were on average at 34 minutes against a target of 18 minutes and in 9 out of 10 calls the response time was 1 hour 29 minutes against a target of 40 minutes.

(1) Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.
(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.