Derek Shaw · Prevention of Future Deaths report

On the 25ᵗʰ May 2022 an inquest was opened into the death of Derek Shaw. At the inquest hearing on 11ᵗʰ November 2022 I concluded with a narrative conclusion “He died as a consequence of a soft tissue haemorrhage into his anterior abdominal wall following a fall, contributed to by a delay in an ambulance being available to attend to him.”

(1) Derek Shaw fell at home on the 21ˢᵗ December and the following morning became unwell. He called an ambulance at 12.52 and the ambulance call was classified as a category 3 call meaning the target time to reach him was 120 minutes.

(2) Capacity meant that no ambulance could be dispatched and whilst he was initially dispatched at 15.46 this ambulance was diverted to a higher priority call. He deteriorated and the ambulance service were contacted again and the category of his call upgraded at 16.46 when he was still conscious.

(3) By the time the ambulance crew arrived at 17.12, he had suffered a cardiac arrest and attempts at resuscitation were unsuccessful.

(4) A post mortem examination revealed that he had died as a consequence of a soft tissue haemorrhage into his anterior abdominal wall as a consequence of the fall. The Pathologist gave evidence that this was an unusual cause of death and earlier intervention would have meant it likely Mr. Shaw would have survived.

(5) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps could be taken by them to Prevent Future Deaths as they had already put steps in place in so far as they were able.

(1) Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.

(2) The East of England Ambulance Service indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem involving local NHS Trusts and their capacity not just the ambulance service themselves.