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Investigation and inquest
On 17 August 2022 I commenced an investigation into the death of Geoffrey Douglas HOAD aged 85. The investigation concluded at the end of the inquest on 07 September 2023.
The medical cause of death was:
1a) Sub Acute Myocardial Infarction
1b) Coronary Artery Atherosclerosis
1c)
2) Hospital Admission for Post Operative Ileus
The conclusion of the inquest was:
Mr Hoad underwent an appropriate, elective medical procedure on 3 August 2022, following which a paralytic ileus was diagnosed. Mr Hoad’s condition fluctuated and did not respond to conservative management. The decision was made to transfer Mr Hoad to Norfolk and Norwich University Hospital at approximately 18.00 on 6 August 2022 and an ambulance called. The ambulance arrived at 08.26 hours on 7 August 2022. Mr Hoad’s condition continued to fluctuate. At 18.50 Mr Hoad rapidly deteriorated and he died at 23.45 hours.
Circumstances of the death
On 3 August 2022, Mr Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.
Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.
Mr Hoad was transported to Norfolk and Norwich University Hospital. At 11.30 am ECG was undertaken which showed signs of cardiac ischaemia. The evidence does not reveal whether this ECG was reviewed. The cardiac ischaemia was not noted and acted upon at this time. By 18.52 Mr Hoad clinically deteriorated with continued low blood pressure and increased oxygen requirements. A repeat ECT showed ongoing ischaemia which was recognised and Mr Hoad was taken to Critical Care Complex at 20.18 hours with a diagnosis of myocardial infarction. Despite treatment, Mr Hoad continued to deteriorate and he died later that day on 7 August 2022.
Coroner’s concerns
1. The ambulance service was called on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours.
2. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.
3. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.
4. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.
5. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.
6. Evidence was heard as to the very high call demand overnight on 6th and 7th August 2022 and with regard to the number of ambulances waiting at Hospitals in the region to hand over patients and as to the significant pressure the healthcare system was under.
7. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system, including by way of training, recruitment, working with other ambulance services to develop a shared plan for these circumstances and also by way of collaboration with local acute and mental health hospitals in the area to look at ways to attempt to alleviate the difficulties experienced.
8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue.
Information checked against the published report and official responses