Colonel John Frederick Codd · Prevention of Future Deaths report

On 29/7/24, I concluded the inquest into the death of Colonel John Frederick Codd (Bill) who died on 16/1/24 at the age of 88.

I recorded the cause of death as:
1a) Massive rectus sheath haematoma and severe coronary artery atherosclerosis;
II) Essential hypertension.

I recorded a Narrative conclusion that Colonel Codd died from an Accident. There was a delay in the arrival of an ambulance and a further delay in admitting Colonel Codd from the ambulance into the Emergency Department. It is probable that an earlier admission into ED would have resulted in an earlier CT scan that would have revealed the haematoma that developed. It is possible that a blood transfusion could have been arranged that may have avoided the outcome.

On 16/1/24, Colonel Codd fell over while exiting a taxi that had collected him after an appointment with his GP. An ambulance was called at 12:31 and the initial disposition was for a Category 3 response requiring 90% of attendances within 2 hours and an average of 60 minutes. The ambulance arrived at 14:49, left the scene at 15:46 and arrived at Royal Cornwall Hospital at 16:30. Although there was a delay in ambulance attendance, I felt this was relatively modest and unlikely to have been a contributory factor in the death.

National guidance requires a handover to hospital staff within 15 minutes. Unfortunately, the hospital was full and Colonel Codd remained in an ambulance outside the hospital until he was brought into a bed in the Majors area of the ED at 21:11, approximately 4 hours and 40 minutes after arrival. At 22:11, Colonel Codd was found collapsed in cardiac arrest. He could not be resuscitated.
At inquest, I heard from ████████, one of the ED consultants at the hospital. I accepted his evidence that had there been a timely admission;
- An x-ray to confirm/exclude a hip fracture would have been conducted earlier;
- A CT scan ordered to elucidate the findings of the x-ray would then have been ordered earlier (the CT was not conducted);
- It was probable that the CT scan would have revealed the haematoma from which Colonel Codd died;
- It was possible that a blood transfusion could have been organised that would have avoided the death.

1) At the time of these events, (January 2024) monthly crowding analysis, that is the total amount of time patients spent waiting for beds or transport after a decision ‘ready to discharge’ from ED was made totalled 23,875 hours, the equivalent of closing 32 cubicles to ED for 24 hours/day for a whole month.
2) Last month, in June 2024, the situation had improved but still totalled 16,245 hours of lost time, the equivalent of closing 22 cubicles for an entire month.

████████ was clear in his evidence that significant pressures remained on the ED at Royal Cornwall Hospital which had the potential to affect future patient care.