Maureen Woods · Prevention of Future Deaths report

On 17 April 2019, I commenced an investigation into the death of Maureen Woods.

The investigation concluded at the end of an inquest, heard on 11 July 2019. The conclusion of the inquest was that Mrs Woods died as a result of natural causes from:

1a. Acute Left Ventricular Failure
1b. Anterior Myocardial Infarction
1c. Ischaemic and Hypertensive Heart Disease
2. Previous Myocardial Infarction and COPD

Maureen Woods died on 26 January 2019 whilst a patient at the Emergency Department of Bassetlaw District General Hospital, Nottinghamshire.

An ambulance was summoned by a concerned neighbour dialling 999 at 00.29 hours on 26 January 2019 to request assistance for Mrs Woods. It was reported that she was “half passed out”, “had difficulty breathing”, “had a tight chest”, “looked pale, clammy and felt nauseous”, and “had a history of heart attack”. The 999 call was triaged in line with national protocol for a primary complaint of chest pain and graded as a category 2 response. Due to overwhelming demand on the ambulance service that night, the ambulance did not attend to Mrs Woods within the prescribed target time of 18 to 40 minutes for a category 2 call.

At 0126 hours a further 999 call was made by the neighbour and Mrs Woods went into cardiac arrest during that call. Paramedics attended promptly but failed to administer Amiodarone contrary to National Resuscitation guidance and without good reason.

The delay in dispatching an ambulance and the failure to administer medication represent failings that prevented Mrs Woods from having the best possible chance of survival. However, it cannot be concluded on a balance of probabilities that either of these failings have caused or contributed to her death.

The evidence from the witnesses employed by EMAS confirmed that Mrs Woods was most likely suffering a cardiac event when the first call was made, but because she wasn’t in cardiac arrest, the call was appropriately graded as a category 2 response, meaning that a resource should arrive with the patient within 18 to 40 minutes. Both EMAS witnesses agreed that 40 minutes appears too long to wait for an ambulance/sole responder when the complainant is chest related and most likely a cardiac event. The EMAS witnesses told me that the Trust were ‘surprised’ to see calls such as this being graded as category 2 when the new categorisation system for grading of calls was introduced nationally.

(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times.

(2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response. However, resources do not permit each and every call to be triaged, and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need.