Stuart Knight · Prevention of Future Deaths report

On 29 August 2014 I commenced an investigation into the death of Stuart Knight. The investigation concluded at the end of the inquest on 26 August 2015. The conclusion of the inquest was that Mr Knight died as a result of an accident, the medical cause of death being:

1a. Head Injury with Subarachnoid Subdural Haemorrhage and Skull Fracture

2. Alcohol Excess

In the early hours of 29 August 2014, Mr Knight was found by ████████ lying in a road in Wainfleet. Initially he appeared to be unconscious, ████████ immediately made a 999 call and requested the attendance of an ambulance. ████████ call was timed at 00:04:32, he was informed that the ambulance service was busy and that there would be a delay in their arrival. This call was never cancelled. ████████ stated that some minutes after he made his initial call to the ambulance service Mr Knight (who was apparently intoxicated) managed to stand up. ████████ went on to state that he then observed Mr Knight fall backwards hitting his head on the road with significant impact which caused a loud "popping" sound and resulted in Mr Knight becoming unconscious. ████████ concern was such that at 00:24 he made a further call to the ambulance service and outlined details of Mr Knights fall. Although ████████ spoke with ambulance personnel on the telephone it was not until 01:15 that a Fast Response Vehicle arrived at the scene. It appeared that the Paramedic in the FRV assessed Mr Knights condition and then spoke on the radio to the ambulance service requesting the attendance of a double-crewed ambulance which did not arrive at the scene until 01:28.

In summary, from the time that ████████ made his first call to EMAS it took 1 hr and 11 mins for the FRV to arrive at the scene and 1 hr and 24 mins had elapsed between the 1st call being made and the arrival of the double crewed ambulance. Mr Knight was taken to Pilgrim Hospital and arrived at 02:02 and died later that day.

(I) Significant and unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury.

Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS.

(II)

(III)

(IV)

(V)