Pin
Get email alerts
Request correction
Investigation and inquest
On 10th June 2017 Mr Raymond Henry Davidson (Raymond), aged 69 years, died at his home address. The Inquest, as part of my Investigation, concluded on 27th February 2018, when I recorded a conclusion of Natural Causes Contributed by Neglect.
The Cause of Death following Post-Mortem Examination was: -
Ia Large Bowel Volvulus
Circumstances of the death
On the 9th June 2017 at 15:19, NEAS received a call into 111 from a gentleman to highlight concerns for his brother. At 15:39, the 111 clinician triaged to a GP contact within 2 hours.
On reviewing this call, it was found that this decision was not as robust as it ought to have been.
At 17:45 an Urgent booking was received by ambulance control to arrange an Urgent ambulance within 2 hours to transport Raymond into Queen Elizabeth Hospital. No ambulance attended.
At 20:11 the first welfare call was completed with no worsening symptoms described. This was followed with further welfare calls at 21:54, 23:04 and 00:05 with no worsening symptoms described.
At 01:05 the Call handler called a clinician to highlight the fifth welfare call was about to be carried out, and advice to upgrade the call was given.
At 01:07 the case was therefore upgraded and prioritised as a G2 emergency response (within 30 minutes). No Ambulance attended.
Raymond’s brother rang 999 at 02:02 as Raymond had stopped breathing.
The case was upgraded to a R1 emergency response for within 8 minutes and CPR instructions given.
The Rapid Response arrived on scene at 02:10, but Raymond had sadly passed away before the arrival of the crew.
Coroner’s concerns
I heard evidence that: -
• the recruitment/retention of staff had improved; and
• welfare calls triggered earlier clinician involvement than previously; and
• although there were several other initiatives under way, operational shortages were ongoing.
Raymond’s death highlighted resource issues. There was only so much NEAS could do when they simply did not have enough ambulances to send. At times demand was greater than the resources NEAS had available. The effect of urgent cases being interposed put back those cases appearing to be less urgent. In this case: -
• 10 hours 51 minutes elapsed from the original 111 call;
• 8 hours and 29 minutes after the urgent categorisation; and
• 1 hour 3 minutes after the case was prioritised as a G2 response.
This is the third such report about the same issue that I have written in recent months as I consider that there is a risk of future deaths. An urgent review of resources and their application is needed.
Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly, which may have impacted on the less than robust initial clinical review of Raymond’s condition.
Information checked against the published report and official responses