Clive GOULD · Prevention of Future Deaths report

On 22 July 2013 an investigation commenced into the death of Clive Gould, who was 76 years old. The investigation concluded at the end of the inquest on 11 December 2013. The narrative conclusion of the inquest was that Mr Gould died on the morning of 18 July 2013 and that an ambulance was called at 4:18am but did not arrive until 5:47am, the medical cause of death being Congestive Cardiac Failure.

1. Mr Gould had a complex past medical history of small cell lung cancer, pulmonary embolism, vasculitis, interstitial lung disease, emphysema, atrial fibrillation, hypertension, left ventricular dysfunction and previous bladder cancer.

2. He was receiving chemotherapy for his lung cancer and had last received treatment on 17 July 2013.

3. During the early hours of 18 July he awoke complaining of sickness and shortness of breath and his wife rang the ambulance at 4:18am. Despite five follow up calls the ambulance did not arrive until 5:47am.

4. Sadly, Mr Gould had gone into cardiac arrest by the time the ambulance arrived and could not be revived.

5. At 6:22am death was confirmed.

(1) The original call made by ████████ was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions. An internal audit of that call suggests that a different priority could have been given to the original call and the presenting concerns of Mr Gould's status.

I recommend that SCAS review how they allocate priority to calls such as this one and identify whether any improvements to the allocation of priority should be given.

(2) In evidence before the inquest SCAS indicated that there was little resilience in the system to tolerate absence or sudden sickness of personnel at certain times.

My recommendation is that SCAS look at the resilience, particularly in rural areas, to consider whether further resources may need to be deployed.

(3) The evidence from the family at the inquest was that they were informed that an ambulance would be arriving shortly. Had they known that there was to be the delays that occurred because other calls had been given priority, they informed me that they could have used first aid resources available to them within the village, such as locally trained first aiders etc.

My recommendation was that SCAS review what information they give callers and to consider whether communication in relation to estimated times of arrival should be notified to callers of the possibility of delays.