Dorothy Anne Jones · Prevention of Future Deaths report

On 11/04/2022 an investigation was opened into the death of Dorothy Anne Jones

The investigation concluded at the end of the inquest on: 17/01/2023

The conclusion of the inquest was recorded as:

A narrative conclusion in the following terms:

Dorothy Anne Jones died at home on 29/03/22 from the effects of bronchopneumonia. Her death was contributed to by the failure of Welsh Ambulance Services NHS Trust to convey Mrs Jones to hospital within a reasonable timescale as dictated by her poor clinical condition.

The medical cause of death was:

1a Bronchopneumonia
2. Advanced multiple Sclerosis

On 22/03/22, Dorothy Anne Jones developed a chest infection. After failing to respond to antibiotics, she was seen at home by ████████ her GP on 29/03/22. ████████ considered that Mrs Jones needed to be admitted immediately to hospital.

Mrs Jones had low oxygen levels and was drowsy and ████████ requested that an ambulance attends within 2 to 3 hours. Following discussion with the ambulance service they informed ████████ that there was a 2- 4 hour wait but that they would attempt to send an ambulance quicker.

Unfortunately, the pressure on the ambulance service and a failure to identify an earlier available resource meant that paramedics did not attend until 20:28, over 9 hours later.

On arrival, paramedics confirmed that Mrs Jones had died and could not be revived.

On hearing the evidence, I determined that a failure to send an ambulance within a timescale required by the severity of Mrs Jones’s illness, contributed to her death.

1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent, where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients.
2. The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need.
3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited. However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines.
4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed, under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response.