Marjorie McMahon · Prevention of Future Deaths report

On the 26th March 2018 an inquest was opened into the death of Marjorie McMahon. The evidence was heard at inquest on the 21st June 2018 and my conclusions were given on the same date. The conclusion left was:

Natural Causes.

The medical cause of death was:

1a Community acquired pneumonia
II Dementia

On the 3th March 2018 Mrs McMahon was noted to be chesty by a staff member at Cherry Tree House. Her condition did not cause staff concern until the morning of the 7th March 2018 when attempts were made to contact her GP without success. At 1.30 pm on the 7th March 2018 an ambulance was called after staff contacted “111” for advice regarding Mrs McMahon's deteriorating condition. Due to heavy demand on the service, a paramedic was unable to attend until 2.58 pm. The paramedic provided oxygen and fluid treatment to Mrs McMahon and an ambulance subsequently arrived at 3.30 pm to convey her to A&E at Stepping Hill Hospital. On arrival at hospital she was assessed and commenced on intravenous antibiotics. Despite treatment, her condition continued to decline and she passed away on the 8/3/2018.

Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7th March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not attended to for nearly 1 ½ hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance). The guideline response time was confirmed to be 8 minutes.