Pin
Get email alerts
Request correction
Investigation and inquest
On the 29ᵗʰ August 2018, I commenced an investigation into the death of Mr Gordon Gillott. The investigation concluded with a Form B being issued by me.
The cause of death after post mortem was:
1a Septicaemia;
1b Necrotic perforated non-reducible left inguinal scrotal bowel hernia; and
II Chronic Obstructive Pulmonary Disease and left common iliac aneurysm (operated)
Circumstances of the death
i) Mr Gillott presented at Chesterfield Royal Hospital on the 8 August 2018 with a ruptured abdominal aneurism. He was transferred to the Royal Derby Hospital for repair of this. He initially survived the surgery but sadly passed away due to sepsis, secondary to a bowel perforation, not related to the surgery he received.
ii) During the course of my investigation I received a letter from the Consultant General and Vascular Surgeon who completed Mr Gillott’s surgery. This highlighted Mr Gillott’s Transfer to the Royal derby Hospital was delayed substantially. It took over 2 hours for an ambulance to attend for the transfer. Multiple calls were made to the East Midlands Ambulance Service both by emergency staff at the Chesterfield Royal Hospital and the operating Consultant himself. The importance of the rapid transfer was emphasised on each occasion. On one occasion it was stressed that Mr Gillott would die if he was not transferred urgently.
iii) Enquiries revealed the initial call requesting transfer was made to the East Midlands Ambulance Service at 05:28. This transfer was assigned at 06:59. Ambulance arrival at Chesterfield Royal Hospital for transfer was at 07:22.
iv) The Consultant Surgeon has said that whilst he does not believe that the delay contributed to Mr Gillott’s death, he has significant concerns that such a delay could be repeated and, under different circumstances, might in fact impact upon patient care, up to and including death of a patient.
v) East Midlands Ambulance Service have responded with a report. This states that the call was received at 05:28 and was classified as a Category 2 call. This required conveying a resource to arrive with the patient within 18 minutes. Resourcing issues meant that the ambulance was allocated at 6:59 and arrived at Chesterfield Royal Hospital at 07:22. The report details that the call was processed correctly and that dispatch actions were correctly with staff repeatedly looking for convoyancing resources.
vi) The delay in response time was due to resourcing issues.
Coroner’s concerns
1. Whilst this delay did not affect Mr Gillott, were this to happen again in the future, there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues.
Information checked against the published report and official responses