Shiya Jonathan Barnard Collins · Prevention of Future Deaths report

On 30th April 2022 I commenced an investigation into the death of Shiya Jonathan Barnard Collins, aged 23. The investigation concluded at the end of the inquest on 27th October 2023. The medical cause of death was 1a) Haemorrhagic hypovolaemic cardiac arrest; 1b) An incised wound to the right lower limb.

Shortly after 10pm on the evening of 29th April 2022 Shiya Jonathan Barnard Collins kicked the glass panel of a door which cracked and caused a laceration to his leg. An ambulance was requested shortly before 10.30pm but the highest priority response (Category 1) was not generated. Further calls to the ambulance service were made but the computer system prevented clinicians from being able to upgrade the category of call despite information indicating that Shiya Collins was suffering significant blood loss and his clinical condition was deteriorating. The paramedic arrived 45 minutes after the first 999 call was made. By that time Shiya Collins had sustained catastrophic blood loss which caused him to suffer a cardiac arrest from which he could not be revived.

(1) Seven calls were made to the North East Ambulance Service (following the initial call) indicating that Shiya Collins’ condition was deteriorating. Call handlers recognised the need for clinical input in order to facilitate a possible upgrade of the ambulance response to category 1. However, the locking facility on the Cleric computer system used in the control room precluded any clinician from assessing/upgrading the call because the system was locked and unable to be accessed whilst live calls relating to the case were ongoing.