David John Briggs · Prevention of Future Deaths report

On 20 June 2023 I commenced an investigation into the death of David John BRIGGS. The investigation concluded at the end of the inquest on 30 November 2023. The conclusion of the inquest was that Mr David Briggs, died on 15 November 2022 at the Northern General Hospital, Sheffield from an infection resulting from catheterisation.

The medical cause of death was:

1a. Urosepsis

1b. Urinary tract obstruction

1c. Spina bifida

Mr Briggs had spina bifida with paralysis from the waist downwards and resided in supported living where he relied heavily on support staff for everyday living. He had a long term supra pubic catheter and colostomy and in early November 22 Mr Briggs's carers became concerned that his catheter wasn't draining properly and with engagement with primary care Mr Briggs was prescribed antibiotics for a possible urinary tract infection on 12 November 2023.

At 2049 on 14 November Mr Briggs's carers called 999 as he was struggling to breath. The call was routed to Yorkshire Ambulance Service (YAS) who coded the call as a Category 2 (expected response within 40 minutes).

At 2145 a second 999 call was made which was answered by East Midlands Ambulance Service (EMAS) having been routed by BT. This call was also coded as a Category 2 and passed to YAS.

At 2219 a third 999 call was made and answered by YAS as Mr Briggs's breathing was worse and he was struggling to breath in-between talking. This call was again coded as a Category 2.

At 2339 a fourth 999 call was made which was again answered by EMAS. This call was incorrectly coded as a Category 2 by EMAS, instead of a Category 1 and passed to YAS.

At 0027 the final 999 call was made. Mr Briggs was unresponsive and not breathing. The call was coded as a Category 1 and carers advised to start CPR. The YAS ambulance arrived at 0044 and after initial treatment David was transferred to the Northern General Hospital in Sheffield where he was pronounced dead at 0231.

(1) The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022.

(2) YAS were not resourced to respond to the number of emergency calls.

(3) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.