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Investigation and inquest
On the 27th of March 2013 I commenced an investigation into the death of Frederick Douglas Pring (DOB 2.03.1938, DOD 21.03.2013). The investigation concluded at the end of the inquest on the 20th of January 2014 and I recorded a narrative conclusion in respect of the death in the following terms: -
On the evening of the 20th of March 2013, Fred Pring began to experience chest pains and at 01.08 the following morning, his wife telephoned 999 and requested help for her husband by way of the attendance of an ambulance at their home address of ████████
Due to a combination of delays in handing over patients at hospitals and ambulance crews being on rest breaks, there were no resources available to allocate to this call nor to the further two calls made by ████████ at 01.19 and 01.38.
Following a fourth and final call at 01.51 in which ████████ informed the call handler that her husband had died a few minutes earlier, three ambulances reached the property, the first of these arriving some 48 minutes after the initial call. The crew of this ambulance implemented their Recognition of Life Extinct policy verifying his death at his home address on the 21st of March 2013. A post mortem later established that Fred Pring had died from a combination of the natural disease processes of Ischaemic Heart Disease and Severe Chronic Obstructive Pulmonary Disease.
Although it cannot be established with certainty that Mr Pring would have survived if help had reached him sooner, it is probable that if an ambulance had arrived promptly after the first call, (that is to say within their target response time of eight minutes), he would have lived long enough to be transported to hospital where further medical treatment would have aided the prospects of his survival.
Circumstances of the death
The Circumstances of the death are as set out in the narrative conclusion appearing in paragraph 3 hereof.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
