Henry Michael WILLEMS · Prevention of Future Deaths report

On 11 March 2024 I commenced an investigation and opened an inquest into the death of Henry Michael Patrick WILLEMS. The investigation concluded at the end of the inquest on 21 October 2024.

The conclusion of the inquest was that Mr. Willems “died from natural causes, to which the lack of a timely ambulance response contributed.”

In answer to the questions “when, where and how did Mr. Willems come by his death?”, I recorded as follows:

“In the early hours of 12.10.23 Mr. Willems, who had been unwell with gastritis over the preceding 48 hours, collapsed at his home in Malvern. His family called the emergency services, and paramedics attended him at home, but he was confirmed deceased a short time later. Paramedics had been unable to attend Mr. Willems’ address within the mean target response time for a Category 2 case because ambulances were experiencing significant delays in handing their patients over to staff at hospital emergency departments across the region. Had that mean target response time been met, it is likely that Mr. Willems would have survived.”

A post mortem examination confirmed the medical cause of death for Mr. Willems was:

1a ischaemic heart disease.

1) In the course of the inquest, I heard evidence from the Patient Safety Learning Lead for West Midlands Ambulance Service University NHS Foundation Trust ( WMAS ), who told me:

(a) Mr. Willems’ case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90ᵗʰ percentile response time is 40 minutes;
(b) Those response times were not met, as Mr. Willems was not reached by paramedics until some 2 hours 18 minutes after the “clock start” time for his case;
(c) The Trust was unable to meet the applicable mean and 90ᵗʰ percentile response times, because at the time of these events, it was operating at Emergency and Urgent Service Level 4 (the highest level which can be applied ). The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.

2) I heard expert evidence that Mr. Willems would probably have survived this episode, and would not have died when he did, had paramedics been able to attend his home address within the applicable 18 minute mean response time.