William Robert Raymond Nute · Prevention of Future Deaths report

The inquest into the death of William Robert Raymond Nute was opened on 25th February 2016 after an investigation was opened on the 17th July 2015. Mr Nute was born on the 6th April 1931 and died on the 2nd July 2015. An inquest was held at 1.00 pm on 2nd March 2016

William Nute had come out the Spar shop with his shopping in Tintagel where he lived. He was crossing the loading bay near the Spar Shop, Fore Street, Tintagel when he fell while a Ford Focus car registration number ML15 2RY was reversing in his direction at around 11.45 am on 30th June 2015. It was not clear whether the car hit Mr Nute or how he fell. An ambulance was called at around 11.45 detailing that Mr Nute had been hit by a car (log attached) but despite a target response time of 30 minutes the first ambulance resource did not arrive until 12.35. On arrival an ambulance was requested at 12.40 but despite a response time of 30 minutes did not arrive until 1.44 pm. For reasons unknown, Mr Nute did not arrive at the Royal Cornwall Hospital, Treliske, Truro until 16.14 pm. He was admitted and diagnosed with a fractured neck of femur. Due to his immobility, the stress on his existing heart disease and the fractured neck of femur he developed pneumonia. He deteriorated and died on 2nd July 2015. The pathologist gave the cause of death 1a pneumonia 1b immobility and congestive cardiac failure 1c Fractured neck of femur (not operated) II Chronic kidney disease and the inquest concluded that Mr Nute died as a result of an accident.

The South Western Ambulance representative gave evidence that the reason that they attended outside their target times was because of a high demand on the service at that time. She was satisfied that all efforts were made to locate resources and there were no lost opportunities. Despite the fact that the ambulance service had been informed at around 11.45 am on 30th June that Mr Nute had an injury as a result of being hit by car, the police were not informed until 12.55 and they did not attend until 13.14 pm. The result was the Mr Nute an elderly gentleman of 84 was left lying on a public highway (albeit in a layby) from 11.45 to at least 1.44 pm in the heat without emergency service support despite repeat calls from the public who were concerned for his welfare and dignity. Both the pathologist and treating doctor gave the opinion that the delay in transfer to hospital did not assist his recovery from the fall.

That the delay in attending and transferring Mr Nute increased his risk of not recovering from his fall/fracture or the trauma of the incident which in turn increasing his risk of death.

That the 999 calls from the public were not triaged by the call handlers at BT or South Western Ambulance appropriately and managed.

That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately. For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway.