Joyce Phoebe Mary LONG · Prevention of Future Deaths report

On 12th July 2018 I commenced an investigation into the death of Joyce Phoebe Mary LONG. The investigation concluded at the end of the inquest on 19th December 2018.
The conclusion was that Mrs Long died as a result of an accident.
The medical cause of death was: 1a Acute subdural haematoma; 2. Atrial Fibrillation (treated with Warfarin)

Mrs Long died at John Radcliffe Hospital, Oxford at 0034 hours on 11th July 2018 from injury sustained when she struck her head in her bedroom at her home address on the morning of 10th July 2018, leading to her collapsing later that afternoon.

(1) Shortly after Mrs Long had been mobilised into an ambulance outside her home address in Hazlemere, near High Wycombe, Buckinghamshire, her condition deteriorated very quickly and her Glasgow Coma Score dropped from 15/15 to 3/15. Her breathing became abnormal and irregular and she became unresponsive. Although the overall intention was to transport to John Radcliffe Hospital as a result of the traumatic head injury, the ambulance crew contacted and requested assistance from the nearest hospital, Wycombe Hospital, due to the concern over Mrs Long’s compromised airway.
Admission was refused with an instruction to attend the nearest Accident & Emergency Unit so, instead, roadside assistance was provided to the crew near Stokenchurch at the M40 junction from an Enhanced Care Response Unit whilst en route to John Radcliffe Hospital.
Due to the severity of the injury Mrs Long had sustained, exacerbated over the day prior to collapse by her warfarin prescription, the refusal of assistance by Wycombe Hospital (part of Buckinghamshire Healthcare NHS Trust) did not impact upon the outcome in this case.
There was, however, a clear difference of opinion between South Central Ambulance Service and Buckinghamshire Healthcare NHS Trust as to the interpretation of the reception policy appropriate to the Cardiac and Stroke Unit at Wycombe.
It is understood that informal discussions have been had between both trusts about whether South Central Ambulance Service should or should not be seeking assistance from Wycombe Hospital (where it is the nearest facility) in cases where a compromised airway may lead to cardiac arrest.
There is a continuing concern that, in the absence of a clear, formalised understanding, circumstances may arise where either help to stabilise a patient’s airway is refused, or a delay occurs as a result of confusion, and a patient dies as a consequence.